Provider Demographics
NPI:1235308578
Name:ADVANCED SPINE SOLUTIONS PA
Entity Type:Organization
Organization Name:ADVANCED SPINE SOLUTIONS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-310-8783
Mailing Address - Street 1:2813 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6829
Mailing Address - Country:US
Mailing Address - Phone:817-310-8783
Mailing Address - Fax:817-431-0735
Practice Address - Street 1:261 W SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7046
Practice Address - Country:US
Practice Address - Phone:817-310-8783
Practice Address - Fax:855-640-3872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4201261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194675801Medicaid
TX0059QHOtherBCBS
TX194675802Medicaid
TX194675803Medicaid
TX0059QHOtherBCBS
TX194675802Medicaid