Provider Demographics
NPI:1639148463
Name:SPINE, ORTHOPEDIC AND PAIN CENTER PC
Entity Type:Organization
Organization Name:SPINE, ORTHOPEDIC AND PAIN CENTER PC
Other - Org Name:SPINE & PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MARTIRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-751-7750
Mailing Address - Street 1:121 W CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1402
Mailing Address - Country:US
Mailing Address - Phone:701-751-7750
Mailing Address - Fax:701-751-7734
Practice Address - Street 1:121 W CENTURY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1402
Practice Address - Country:US
Practice Address - Phone:701-751-7750
Practice Address - Fax:701-751-7734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01060/002OtherBCBS GROUP NUMBER
ND13043Medicaid
ND01060/002OtherBCBS GROUP NUMBER