Provider Demographics
NPI:1376902775
Name:ADVANCED SPINE AND PAIN CENTER, P.A.
Entity Type:Organization
Organization Name:ADVANCED SPINE AND PAIN CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHID
Authorized Official - Middle Name:
Authorized Official - Last Name:IDRISSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-339-8475
Mailing Address - Street 1:518 SANDHURST DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:518 SANDHURST DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4426
Practice Address - Country:US
Practice Address - Phone:910-339-8475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022043AMedicare PIN