Provider Demographics
NPI:1770815300
Name:PREMIER SPINE PAIN & REHABILITATION
Entity Type:Organization
Organization Name:PREMIER SPINE PAIN & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:OVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:704-817-6676
Mailing Address - Street 1:PO BOX 480328
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5338
Mailing Address - Country:US
Mailing Address - Phone:215-669-9668
Mailing Address - Fax:
Practice Address - Street 1:2315 W ARBORS DR STE 115
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2639
Practice Address - Country:US
Practice Address - Phone:704-817-6676
Practice Address - Fax:704-817-6678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-07
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004009342081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty