Provider Demographics
NPI:1508365446
Name:SPINE CIN OF PHILADELPHIA LLC
Entity Type:Organization
Organization Name:SPINE CIN OF PHILADELPHIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LELAND HUTTON
Authorized Official - Last Name:EADIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-733-2064
Mailing Address - Street 1:102 WOODMONT BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2216
Mailing Address - Country:US
Mailing Address - Phone:615-386-0064
Mailing Address - Fax:615-386-0067
Practice Address - Street 1:1700 MARKET ST STE 1005B216
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-3913
Practice Address - Country:US
Practice Address - Phone:615-386-0064
Practice Address - Fax:615-386-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty