Provider Demographics
NPI:1720680119
Name:MIISPINE
Entity Type:Organization
Organization Name:MIISPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VENU
Authorized Official - Middle Name:
Authorized Official - Last Name:VEMURI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-242-6370
Mailing Address - Street 1:6420 DUTCHMANS PKWY STE 160
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3353
Mailing Address - Country:US
Mailing Address - Phone:502-242-6370
Mailing Address - Fax:502-242-6540
Practice Address - Street 1:6420 DUTCHMANS PKWY STE 160
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3353
Practice Address - Country:US
Practice Address - Phone:502-242-6370
Practice Address - Fax:502-242-6540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-11
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty