Provider Demographics
NPI:1134517527
Name:NEUROLOGICAL SPINE AND PAIN
Entity Type:Organization
Organization Name:NEUROLOGICAL SPINE AND PAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-656-3023
Mailing Address - Street 1:8880 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4508
Mailing Address - Country:US
Mailing Address - Phone:912-656-3023
Mailing Address - Fax:912-231-4440
Practice Address - Street 1:8880 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4508
Practice Address - Country:US
Practice Address - Phone:912-231-4444
Practice Address - Fax:912-231-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058635207LP2900X, 207LP2900X
GARN140169363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003158386AMedicaid
GA003158386AMedicaid