Provider Demographics
NPI:1639317332
Name:ADVANCED SPINE AND PAIN CENTER, P.A.
Entity Type:Organization
Organization Name:ADVANCED SPINE AND PAIN CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RACHID
Authorized Official - Middle Name:
Authorized Official - Last Name:IDRISSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-894-1740
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504
Mailing Address - Country:US
Mailing Address - Phone:919-894-1740
Mailing Address - Fax:919-894-2701
Practice Address - Street 1:1 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-1177
Practice Address - Country:US
Practice Address - Phone:919-894-1740
Practice Address - Fax:919-894-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2014-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-005872081P2900X
208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2022043AMedicare PIN