Provider Demographics
NPI:1255563227
Name:MAI SPINE CENTER
Entity type:Organization
Organization Name:MAI SPINE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DUNG
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-227-9606
Mailing Address - Street 1:485 ARUNDEL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1931
Mailing Address - Country:US
Mailing Address - Phone:651-797-3866
Mailing Address - Fax:651-207-5395
Practice Address - Street 1:485 ARUNDEL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1931
Practice Address - Country:US
Practice Address - Phone:651-797-3866
Practice Address - Fax:651-207-5395
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAI SPINE CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-10
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 207RM1200X
MN4848111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)Group - Multi-Specialty