Provider Demographics
NPI:1467540179
Name:SPINECARE MEDICAL GROUP
Entity Type:Organization
Organization Name:SPINECARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAGUESPACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-392-7123
Mailing Address - Street 1:3939 HOUMA BLVD STE 18
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2921
Mailing Address - Country:US
Mailing Address - Phone:504-392-7123
Mailing Address - Fax:504-392-7823
Practice Address - Street 1:3939 HOUMA BLVD STE 18
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2921
Practice Address - Country:US
Practice Address - Phone:504-392-7123
Practice Address - Fax:504-392-7823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09377R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1955884Medicaid
LAF45378Medicare UPIN
LA5CW25Medicare PIN
LA1955884Medicaid