Provider Demographics
NPI:1437344041
Name:SPINE & INJURY CENTER OF FREDERICKSBURG PC
Entity Type:Organization
Organization Name:SPINE & INJURY CENTER OF FREDERICKSBURG PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:RENO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-785-0200
Mailing Address - Street 1:4500 PLANK RD
Mailing Address - Street 2:SUITE 1022
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-0120
Mailing Address - Country:US
Mailing Address - Phone:540-785-0200
Mailing Address - Fax:540-785-0660
Practice Address - Street 1:4500 PLANK RD
Practice Address - Street 2:SUITE 1022
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-0120
Practice Address - Country:US
Practice Address - Phone:540-785-0200
Practice Address - Fax:540-785-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555960305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2101714OtherALLIANCE
VA2740701OtherAETNA
VA434855OtherANTHEM
VA50576OtherNVPPO
VAS974-0001OtherCAREFIRST
VA2101714OtherMAMSI
VA350001199Medicare PIN