Provider Demographics
NPI:1326583006
Name:ADVANCED SPINE ENDOSCOPY AND PAIN INSTITUTE
Entity Type:Organization
Organization Name:ADVANCED SPINE ENDOSCOPY AND PAIN INSTITUTE
Other - Org Name:SKY SPINE ENDOSCOPY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-367-9601
Mailing Address - Street 1:1003 W 7TH ST STE 503
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-8512
Mailing Address - Country:US
Mailing Address - Phone:240-367-9601
Mailing Address - Fax:301-663-5747
Practice Address - Street 1:1003 W 7TH ST STE 503
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-8512
Practice Address - Country:US
Practice Address - Phone:240-367-9601
Practice Address - Fax:301-663-5747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0055038207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1023071206Medicare UPIN