Provider Demographics
NPI:1598454381
Name:NOVA SPINE CENTER LLC
Entity Type:Organization
Organization Name:NOVA SPINE CENTER LLC
Other - Org Name:NOVA SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHASTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-599-9872
Mailing Address - Street 1:649 DEERFIELD FARM CT
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-3934
Mailing Address - Country:US
Mailing Address - Phone:410-599-9872
Mailing Address - Fax:
Practice Address - Street 1:46090 LAKE CENTER PLZ STE 102
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5877
Practice Address - Country:US
Practice Address - Phone:410-599-9872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-05
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty