Provider Demographics
NPI:1073746152
Name:INTERVENTIONAL SPINE & SPORTS INSTITUTE
Entity Type:Organization
Organization Name:INTERVENTIONAL SPINE & SPORTS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:TRUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-296-2552
Mailing Address - Street 1:PO BOX 17708
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-7708
Mailing Address - Country:US
Mailing Address - Phone:601-296-2552
Mailing Address - Fax:601-296-2552
Practice Address - Street 1:105 ASBURY CIR STE B
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1397
Practice Address - Country:US
Practice Address - Phone:601-296-2552
Practice Address - Fax:601-296-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20628208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty