Provider Demographics
NPI:1376292318
Name:PREMIER SPINE CARE, P.A.
Entity Type:Organization
Organization Name:PREMIER SPINE CARE, P.A.
Other - Org Name:PREMIER SPINE CARE OVERLAND PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CICCARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-322-2700
Mailing Address - Street 1:PO BOX 26250
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66225-6250
Mailing Address - Country:US
Mailing Address - Phone:913-322-2700
Mailing Address - Fax:913-322-7890
Practice Address - Street 1:7840 W 165TH ST STE 280
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-3022
Practice Address - Country:US
Practice Address - Phone:913-322-2700
Practice Address - Fax:913-322-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0430147OtherSTATE LICENSE
KS0431121OtherSTATE LICENSE