Provider Demographics
NPI:1528366598
Name:ATLANTIC BRAIN AND SPINE SURGERY
Entity Type:Organization
Organization Name:ATLANTIC BRAIN AND SPINE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-876-4270
Mailing Address - Street 1:1850 TOWNCENTER PKWY PAV 2 SUITE#559
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3204
Mailing Address - Country:US
Mailing Address - Phone:703-876-4270
Mailing Address - Fax:703-876-4276
Practice Address - Street 1:1850 TOWN CENTER PKWY STE 559
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3300
Practice Address - Country:US
Practice Address - Phone:703-876-4270
Practice Address - Fax:703-876-4276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002433207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366775611OtherINDIVIDUAL NPI