Provider Demographics
NPI:1972668952
Name:MIDWEST BRAIN AND SPINE LLC
Entity Type:Organization
Organization Name:MIDWEST BRAIN AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROSURGEON CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:VITO
Authorized Official - Last Name:MAIORIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-344-8330
Mailing Address - Street 1:3385 DEXTER COURT
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3461
Mailing Address - Country:US
Mailing Address - Phone:563-344-8330
Mailing Address - Fax:563-344-8339
Practice Address - Street 1:3385 DEXTER COURT
Practice Address - Street 2:SUITE 110
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3461
Practice Address - Country:US
Practice Address - Phone:563-344-8330
Practice Address - Fax:563-344-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35413207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI19370Medicare ID - Type UnspecifiedGROUP NUMBER
IA6024430001Medicare NSC