Provider Demographics
NPI:1972890796
Name:BRAIN AND SPINE INSTITUTE OF CALIFORNIA, INC.
Entity Type:Organization
Organization Name:BRAIN AND SPINE INSTITUTE OF CALIFORNIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GOWRIHARAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THAIYANANTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-376-6364
Mailing Address - Street 1:4631 TELLER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8105
Mailing Address - Country:US
Mailing Address - Phone:949-335-7500
Mailing Address - Fax:949-387-1206
Practice Address - Street 1:4631 TELLER AVE STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8105
Practice Address - Country:US
Practice Address - Phone:949-335-7500
Practice Address - Fax:949-335-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103609207LP2900X
CAA31505207R00000X
CAA80845207T00000X
CAA99924207T00000X
CAA135941207XS0117X
CAA1301522081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty