Provider Demographics
NPI:1780121210
Name:TEXAS SPINE AND JOINT HOSPITAL, LLC
Entity type:Organization
Organization Name:TEXAS SPINE AND JOINT HOSPITAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-525-3300
Mailing Address - Street 1:1814 ROSELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4234
Mailing Address - Country:US
Mailing Address - Phone:903-525-3330
Mailing Address - Fax:903-525-3398
Practice Address - Street 1:8101 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5469
Practice Address - Country:US
Practice Address - Phone:903-939-0920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162459501Medicaid
TXTXB138589Medicare PIN