Provider Demographics
NPI:1689768301
Name:ADVANCED NEUROSURGERY LLC
Entity Type:Organization
Organization Name:ADVANCED NEUROSURGERY LLC
Other - Org Name:ADVANCED NEUROSURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-650-2907
Mailing Address - Street 1:3903 S 7TH ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5710
Mailing Address - Country:US
Mailing Address - Phone:812-234-0787
Mailing Address - Fax:812-232-3253
Practice Address - Street 1:3903 S 7TH ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5710
Practice Address - Country:US
Practice Address - Phone:812-234-0787
Practice Address - Fax:812-232-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026616A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200844940AMedicaid
IN200844940AMedicaid
DF6597Medicare PIN