Provider Demographics
NPI:1629422738
Name:ADVANCED SPORTS & SPINE, PLLC
Entity Type:Organization
Organization Name:ADVANCED SPORTS & SPINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:USMAN
Authorized Official - Middle Name:FAYYAZ
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:704-542-3988
Mailing Address - Street 1:8035 PROVIDENCE RD STE 340
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-9717
Mailing Address - Country:US
Mailing Address - Phone:704-542-3988
Mailing Address - Fax:704-542-3912
Practice Address - Street 1:8035 PROVIDENCE RD
Practice Address - Street 2:#340
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-9716
Practice Address - Country:US
Practice Address - Phone:704-542-3988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-014012081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1629422738Medicaid