Provider Demographics
NPI:1902386477
Name:SPINE SURGERY SERVICE, PLLC
Entity Type:Organization
Organization Name:SPINE SURGERY SERVICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-370-3535
Mailing Address - Street 1:1141 N LOOP 1604 E # 105-612
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1339
Mailing Address - Country:US
Mailing Address - Phone:201-598-4262
Mailing Address - Fax:
Practice Address - Street 1:17051 DALLAS PKWY STE 400
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7108
Practice Address - Country:US
Practice Address - Phone:210-598-4262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty