Provider Demographics
NPI:1700910270
Name:ARIZONA MEDICAL SPINE INSTITUTE
Entity Type:Organization
Organization Name:ARIZONA MEDICAL SPINE INSTITUTE
Other - Org Name:ARIZONA BACK INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-503-3344
Mailing Address - Street 1:4530 E RAY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6094
Mailing Address - Country:US
Mailing Address - Phone:480-503-3344
Mailing Address - Fax:480-763-0417
Practice Address - Street 1:4530 E RAY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6094
Practice Address - Country:US
Practice Address - Phone:480-503-3344
Practice Address - Fax:480-763-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ200122081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE28460Medicare UPIN