Provider Demographics
NPI:1447236237
Name:SPINE SURGERY, PSC
Entity Type:Organization
Organization Name:SPINE SURGERY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GADWAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-585-2300
Mailing Address - Street 1:210 E GRAY ST
Mailing Address - Street 2:SUITE 601
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3902
Mailing Address - Country:US
Mailing Address - Phone:502-585-2300
Mailing Address - Fax:502-584-2726
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 601
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3902
Practice Address - Country:US
Practice Address - Phone:502-585-2300
Practice Address - Fax:502-584-2726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINE SURGERY, PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-22
Last Update Date:2008-04-07
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
KY65918583Medicaid
KY65918583Medicaid
IN195720Medicare PIN