Provider Demographics
NPI:1235465683
Name:CENTER FOR ADVANCED INTERVENTIONAL SPINE TREATMENT PLC
Entity Type:Organization
Organization Name:CENTER FOR ADVANCED INTERVENTIONAL SPINE TREATMENT PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:EASA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-796-6430
Mailing Address - Street 1:12662 RILEY ST STE 120
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8023
Mailing Address - Country:US
Mailing Address - Phone:616-796-6430
Mailing Address - Fax:616-786-4324
Practice Address - Street 1:12662 RILEY ST STE 120
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8023
Practice Address - Country:US
Practice Address - Phone:616-796-6430
Practice Address - Fax:616-786-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJE069312207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3441763Medicaid
MI0016150089Medicare UPIN