Provider Demographics
NPI:1518931666
Name:CAROLINA SPINE SPECIALISTS PA
Entity Type:Organization
Organization Name:CAROLINA SPINE SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LOWELL
Authorized Official - Last Name:SMOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-873-0002
Mailing Address - Street 1:4030 WAKE FOREST RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609
Mailing Address - Country:US
Mailing Address - Phone:919-873-0002
Mailing Address - Fax:919-873-0006
Practice Address - Street 1:4030 WAKE FOREST RD
Practice Address - Street 2:SUITE 102
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609
Practice Address - Country:US
Practice Address - Phone:919-873-0002
Practice Address - Fax:919-873-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34163208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E90415Medicare UPIN