Provider Demographics
NPI:1174875587
Name:FIRST STATE SPINE AND PAIN TREATMENT CENTERS
Entity type:Organization
Organization Name:FIRST STATE SPINE AND PAIN TREATMENT CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-439-3063
Mailing Address - Street 1:1600 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-4047
Mailing Address - Country:US
Mailing Address - Phone:302-439-3063
Mailing Address - Fax:302-439-3372
Practice Address - Street 1:1600 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-4047
Practice Address - Country:US
Practice Address - Phone:302-439-3063
Practice Address - Fax:302-439-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1740229046Medicaid