Provider Demographics
NPI:1699846386
Name:FOURTH CORNER NEUROSURGICAL ASSOCIATES INC PS
Entity Type:Organization
Organization Name:FOURTH CORNER NEUROSURGICAL ASSOCIATES INC PS
Other - Org Name:CASCADE OUTPATIENT SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:FLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-319-8615
Mailing Address - Street 1:710 BIRCHWOOD AVE
Mailing Address - Street 2:#101
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1720
Mailing Address - Country:US
Mailing Address - Phone:360-676-0922
Mailing Address - Fax:360-671-4726
Practice Address - Street 1:710 BIRCHWOOD AVE
Practice Address - Street 2:#101
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1720
Practice Address - Country:US
Practice Address - Phone:360-676-0922
Practice Address - Fax:360-671-4726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOURTH CORNER NEUROSURGICAL ASSOCIATES INC PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 207LP2900X
WA207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G001447900Medicare PIN