Provider Demographics
NPI:1689085193
Name:AXIS BRAIN AND BACK INSTITUTE PLLC
Entity Type:Organization
Organization Name:AXIS BRAIN AND BACK INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAEID
Authorized Official - Middle Name:ESMAEILY
Authorized Official - Last Name:ARYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-502-7411
Mailing Address - Street 1:1110 E STATE HIGHWAY 114 STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5251
Mailing Address - Country:US
Mailing Address - Phone:817-502-7411
Mailing Address - Fax:817-502-7412
Practice Address - Street 1:9525 N BEACH ST STE 405
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6438
Practice Address - Country:US
Practice Address - Phone:817-502-7411
Practice Address - Fax:817-502-7412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9148207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E4E2OtherBCBS
7273750001OtherMEDICARE NSC
TX341501001Medicaid
7273750001OtherMEDICARE NSC