Provider Demographics
NPI:1265686125
Name:MISSOURI SPINE INSTITUTE, LLC
Entity Type:Organization
Organization Name:MISSOURI SPINE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPEARS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-635-0401
Mailing Address - Street 1:1616 SOUTHRIDGE DR
Mailing Address - Street 2:STE 202
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5677
Mailing Address - Country:US
Mailing Address - Phone:573-635-0401
Mailing Address - Fax:573-635-6715
Practice Address - Street 1:1616 SOUTHRIDGE DR
Practice Address - Street 2:STE 202
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5677
Practice Address - Country:US
Practice Address - Phone:573-635-0401
Practice Address - Fax:573-635-6715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC0926793207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty