Provider Demographics
NPI:1689872152
Name:SPINE & MUSCULOSKELETAL CENTER PC
Entity Type:Organization
Organization Name:SPINE & MUSCULOSKELETAL CENTER PC
Other - Org Name:SUPERIOR ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:SPOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-397-8648
Mailing Address - Street 1:9430 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9768
Mailing Address - Country:US
Mailing Address - Phone:219-558-8068
Mailing Address - Fax:219-558-8149
Practice Address - Street 1:2020 E COLUMBUS DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3078
Practice Address - Country:US
Practice Address - Phone:219-397-8648
Practice Address - Fax:219-397-8653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2001917207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200184170DMedicaid
IN7538064OtherAETNA
INP00222849Medicaid
IL036105846Medicaid
IL90001235OtherBCBS IL
IN000000373304OtherANTHEM
IN7538064OtherAETNA
IL036105846Medicaid