Provider Demographics
NPI:1649565961
Name:MISSOURI SPINE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MISSOURI SPINE ASSOCIATES, LLC
Other - Org Name:MISSOURI SPINE AND PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABIRAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELANGOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-333-3700
Mailing Address - Street 1:1765 JEFFCO BLVD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2713
Mailing Address - Country:US
Mailing Address - Phone:636-333-3700
Mailing Address - Fax:636-333-3701
Practice Address - Street 1:1765 JEFFCO BLVD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2713
Practice Address - Country:US
Practice Address - Phone:636-333-3700
Practice Address - Fax:636-333-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006037124208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3465Medicare UPIN