Provider Demographics
NPI:1629376157
Name:MINIMALLY INVASIVE SPINE SPECIALIST MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE SPINE SPECIALIST MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-432-1647
Mailing Address - Street 1:PO BOX 25729
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5729
Mailing Address - Country:US
Mailing Address - Phone:559-432-1647
Mailing Address - Fax:559-432-7828
Practice Address - Street 1:1332 W HERNDON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-7118
Practice Address - Country:US
Practice Address - Phone:559-432-1647
Practice Address - Fax:559-432-7828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32342207XS0106X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAS7663265OtherDEA
CAAS7663265OtherDEA
CA00C323420Medicare PIN