Provider Demographics
NPI:1376731596
Name:SPINE AND ORTHOPEDIC PAIN CENTER
Entity Type:Organization
Organization Name:SPINE AND ORTHOPEDIC PAIN CENTER
Other - Org Name:BRAGG SPINE AND ORTHOPEDIC PAIN CENTER PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINIFRED
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-333-3360
Mailing Address - Street 1:6160 KEMPSVILLE CIRCLE
Mailing Address - Street 2:SUITE 303A
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3933
Mailing Address - Country:US
Mailing Address - Phone:757-333-3360
Mailing Address - Fax:757-961-8093
Practice Address - Street 1:6160 KEMPSVILLE CIRCLE
Practice Address - Street 2:SUITE 303A
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3933
Practice Address - Country:US
Practice Address - Phone:757-333-3360
Practice Address - Fax:757-961-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052700208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010209692Medicaid
VA010209692Medicaid
5591580001Medicare NSC
VAC09604Medicare Oscar/Certification
VAC09604Medicare PIN