Provider Demographics
NPI:1497391619
Name:MADISON SPINE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MADISON SPINE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:I
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-321-1504
Mailing Address - Street 1:1080 RIVER OAKS DR STE B103
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7602
Mailing Address - Country:US
Mailing Address - Phone:601-321-1504
Mailing Address - Fax:601-932-6111
Practice Address - Street 1:160 FOUNTAINS BLVD STE C
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6380
Practice Address - Country:US
Practice Address - Phone:601-321-1504
Practice Address - Fax:601-932-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical