Provider Demographics
NPI:1023594801
Name:NEUROSPINE GROUP
Entity type:Organization
Organization Name:NEUROSPINE GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-316-6616
Mailing Address - Street 1:74B CENTENNIAL LOOP STE 300
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7925
Mailing Address - Country:US
Mailing Address - Phone:541-316-6616
Mailing Address - Fax:541-284-3160
Practice Address - Street 1:74B CENTENNIAL LOOP STE 300
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7925
Practice Address - Country:US
Practice Address - Phone:541-686-3791
Practice Address - Fax:541-686-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1033283627OtherCOMMERCIAL
OR1033283627Medicaid
OR1982899274Medicaid
OR1033192760OtherCOMMERCIAL
OR1033192760Medicaid
OR1982899274OtherCOMMERCIAL
OR1184634594OtherCOMMERCIAL
OR1184634594Medicaid
OR1477536100Medicaid
OR1902000599Medicaid
OR1518639038Medicaid
OR1831475573Medicaid
OR1902000599OtherCOMMERCIAL
OR1477536100OtherCOMMERCIAL
OR1831475573OtherCOMMERCIAL