Provider Demographics
NPI:1558754705
Name:NEUROSURGICAL AND SPINE CONSULTANTS, PA
Entity Type:Organization
Organization Name:NEUROSURGICAL AND SPINE CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSCIAN
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-576-6500
Mailing Address - Street 1:1001 12TH AVE STE 171
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3926
Mailing Address - Country:US
Mailing Address - Phone:817-576-6500
Mailing Address - Fax:682-703-2064
Practice Address - Street 1:1001 12TH AVE
Practice Address - Street 2:STE 170
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:214-373-3183
Practice Address - Fax:214-361-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0729174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty