Provider Demographics
NPI:1134329493
Name:SPINE, PLLC
Entity Type:Organization
Organization Name:SPINE, PLLC
Other - Org Name:JEFFREY K. WINGATE, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WINGATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-228-0054
Mailing Address - Street 1:1221 BOWERS ST UNIT 2710
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48012-7106
Mailing Address - Country:US
Mailing Address - Phone:248-566-3313
Mailing Address - Fax:248-566-3316
Practice Address - Street 1:555 BARCLAY CIR STE 140
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4587
Practice Address - Country:US
Practice Address - Phone:248-566-3313
Practice Address - Fax:248-566-3316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088960207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F32509Medicare UPIN