Provider Demographics
NPI:1164789582
Name:EXECUTIVE SPINE SURGERY PC
Entity Type:Organization
Organization Name:EXECUTIVE SPINE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINITRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMENETSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-697-5558
Mailing Address - Street 1:157 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-1004
Mailing Address - Country:US
Mailing Address - Phone:908-452-5612
Mailing Address - Fax:908-452-5624
Practice Address - Street 1:157 HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1004
Practice Address - Country:US
Practice Address - Phone:908-452-5612
Practice Address - Fax:908-452-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09005200207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty