Provider Demographics
NPI:1023079183
Name:HAIDER SPINE CENTER MEDICAL GROUP
Entity type:Organization
Organization Name:HAIDER SPINE CENTER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:HAIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-413-0964
Mailing Address - Street 1:6276 RIVER CREST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0754
Mailing Address - Country:US
Mailing Address - Phone:952-141-3020
Mailing Address - Fax:951-653-5161
Practice Address - Street 1:6276 RIVER CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0754
Practice Address - Country:US
Practice Address - Phone:952-141-3020
Practice Address - Fax:951-653-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18101363AS0400X
CAA107599207XS0117X
CA20A8197207T00000X
CAG81353207XS0117X
CAG61537207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740213594OtherCHAD SWEETNAM
CAGR0086790Medicaid
CA1740213594OtherCHAD SWEETNAM
CA1336353341Medicare UPIN
CA1760691745Medicare UPIN
CA1336100379Medicare UPIN
CAG61537Medicare UPIN
CA5699370001Medicare NSC
CAZZZ37592ZMedicare ID - Type Unspecified