Provider Demographics
NPI:1255373882
Name:NEUROSPINAL SURGERY, PC
Entity type:Organization
Organization Name:NEUROSPINAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKI
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-2580
Mailing Address - Street 1:PO BOX 4520
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-4520
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-991-8960
Practice Address - Street 1:226 S WOODS MILL RD
Practice Address - Street 2:SUITE 54 W
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-388-6513
Practice Address - Fax:314-878-0847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4651174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODB5175OtherRR MEDICARE GROUP#
MO000014163OtherMEDICARE PTAN
MO000014163OtherMEDICARE PTAN
MO=========OtherTAX ID#