Provider Demographics
NPI:1922093434
Name:NORTH CAROLINA SPINE CENTER PA
Entity Type:Organization
Organization Name:NORTH CAROLINA SPINE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-942-1629
Mailing Address - Street 1:101 CONNER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-7038
Mailing Address - Country:US
Mailing Address - Phone:919-942-1629
Mailing Address - Fax:919-929-4019
Practice Address - Street 1:101 CONNER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-7038
Practice Address - Country:US
Practice Address - Phone:919-942-1629
Practice Address - Fax:919-929-4019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28441207XS0117X
NC200301142208100000X
225100000X
NC82622251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCA2725OtherRAILROAD MEDICARE
NCCA2725OtherRAILROAD MEDICARE
NC0917Medicare PIN