Provider Demographics
NPI:1609009505
Name:SPINE TEAM TEXAS, PA
Entity Type:Organization
Organization Name:SPINE TEAM TEXAS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-442-9300
Mailing Address - Street 1:1545 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6422
Mailing Address - Country:US
Mailing Address - Phone:817-442-9300
Mailing Address - Fax:817-796-0763
Practice Address - Street 1:3142 HORIZON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7809
Practice Address - Country:US
Practice Address - Phone:817-442-9300
Practice Address - Fax:817-796-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00957ZOtherMEDICARE PTAN