Provider Demographics
NPI:1720028558
Name:PIEDMONT SPINE SPECIALISTS, PA
Entity Type:Organization
Organization Name:PIEDMONT SPINE SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-781-4541
Mailing Address - Street 1:PO BOX 16934
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-6934
Mailing Address - Country:US
Mailing Address - Phone:919-442-2407
Mailing Address - Fax:919-967-6647
Practice Address - Street 1:3480 WAKE FOREST RD
Practice Address - Street 2:SUITE 208
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7376
Practice Address - Country:US
Practice Address - Phone:919-781-4541
Practice Address - Fax:919-781-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902775Medicaid
NC017P7OtherBLUE CROSS/BLUE SHIELD
NC5902775Medicaid