Provider Demographics
NPI:1659616696
Name:DIAGNOSTIC AND INTERVENTIONAL SPINAL CARE OF LOUISIANA
Entity Type:Organization
Organization Name:DIAGNOSTIC AND INTERVENTIONAL SPINAL CARE OF LOUISIANA
Other - Org Name:DISC OF LOUISIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHADER SAMER
Authorized Official - Middle Name:FAYEZ
Authorized Official - Last Name:SHAMIEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:844-800-3472
Mailing Address - Street 1:76 STARBRUSH CIR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7208
Mailing Address - Country:US
Mailing Address - Phone:844-800-3472
Mailing Address - Fax:844-355-3472
Practice Address - Street 1:76 STARBRUSH CIR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7208
Practice Address - Country:US
Practice Address - Phone:844-800-3472
Practice Address - Fax:844-355-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA334965Medicare PIN