Provider Demographics
NPI:1477982833
Name:PERFORMANCE SPINE & SPORTS SPECIALISTS, PA
Entity Type:Organization
Organization Name:PERFORMANCE SPINE & SPORTS SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:REVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-501-3796
Mailing Address - Street 1:1507 WESTOVER TER
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7130
Mailing Address - Country:US
Mailing Address - Phone:336-501-3796
Mailing Address - Fax:336-333-5477
Practice Address - Street 1:1507 WESTOVER TER
Practice Address - Street 2:SUITE B
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7130
Practice Address - Country:US
Practice Address - Phone:336-501-3796
Practice Address - Fax:336-333-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00213208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty