Provider Demographics
NPI:1780062133
Name:CERVICAL SPINE CENTERS, PLLC
Entity type:Organization
Organization Name:CERVICAL SPINE CENTERS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EHTESHAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-656-4220
Mailing Address - Street 1:20280 N 59TH AVE STE 115-345
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6850
Mailing Address - Country:US
Mailing Address - Phone:480-656-4220
Mailing Address - Fax:480-656-1554
Practice Address - Street 1:20280 N 59TH AVE STE 115-345
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6850
Practice Address - Country:US
Practice Address - Phone:480-656-4220
Practice Address - Fax:480-656-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41787207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ41787OtherAZ MD LICENSE
AZ022926Medicaid
AZZ176477Medicare UPIN