Provider Demographics
NPI:1659885200
Name:MD SPINE AND HEALTH CENTER LLC
Entity Type:Organization
Organization Name:MD SPINE AND HEALTH CENTER LLC
Other - Org Name:MDSH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-422-4688
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48311-0880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27789 MOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2697
Practice Address - Country:US
Practice Address - Phone:313-209-3353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty