Provider Demographics
NPI:1962504761
Name:PACIFICASPINE,PC
Entity Type:Organization
Organization Name:PACIFICASPINE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SIMONSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-585-0231
Mailing Address - Street 1:1752 S VICTORIA AVE STE 220
Mailing Address - Street 2:SUITE # 220
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6151
Mailing Address - Country:US
Mailing Address - Phone:805-585-0231
Mailing Address - Fax:805-482-7940
Practice Address - Street 1:1752 S VICTORIA AVE STE 220
Practice Address - Street 2:SUITE # 220
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6151
Practice Address - Country:US
Practice Address - Phone:805-585-0231
Practice Address - Fax:805-482-7940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20279Medicare PIN