Provider Demographics
NPI:1477020402
Name:ADVANCED SPINE ENDOSCOPY AND PAIN INSTITUTE
Entity Type:Organization
Organization Name:ADVANCED SPINE ENDOSCOPY AND PAIN INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-367-9601
Mailing Address - Street 1:915 TOLL HOUSE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-5901
Mailing Address - Country:US
Mailing Address - Phone:240-367-9601
Mailing Address - Fax:
Practice Address - Street 1:915 TOLL HOUSE AVE STE 207
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5901
Practice Address - Country:US
Practice Address - Phone:240-367-9601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD600218800Medicaid