Provider Demographics
NPI:1972832863
Name:MINIMALLY INVASIVE SPINE CENTER, PA
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE SPINE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:WON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-317-4666
Mailing Address - Street 1:4301 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6497
Mailing Address - Country:US
Mailing Address - Phone:214-317-4666
Mailing Address - Fax:214-317-4667
Practice Address - Street 1:4301 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6497
Practice Address - Country:US
Practice Address - Phone:214-317-4666
Practice Address - Fax:214-317-4667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9018207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C0686Medicare PIN