Provider Demographics
NPI:1669916060
Name:ADVANCED NEUROSPINE SURGERY CENTER, LLC
Entity type:Organization
Organization Name:ADVANCED NEUROSPINE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGNEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD FAANS
Authorized Official - Phone:404-446-4424
Mailing Address - Street 1:9635 VENTANA WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8620
Mailing Address - Country:US
Mailing Address - Phone:404-446-4424
Mailing Address - Fax:404-446-4420
Practice Address - Street 1:9635 VENTANA WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8620
Practice Address - Country:US
Practice Address - Phone:404-446-4424
Practice Address - Fax:404-446-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAME96941261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical