Provider Demographics
NPI:1801277884
Name:SPINAL CENTER OF CHAMPAIGN
Entity type:Organization
Organization Name:SPINAL CENTER OF CHAMPAIGN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOSSETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-351-8040
Mailing Address - Street 1:2009 FOX DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7363
Mailing Address - Country:US
Mailing Address - Phone:217-351-8046
Mailing Address - Fax:
Practice Address - Street 1:2009 FOX DR
Practice Address - Street 2:SUITE C
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7363
Practice Address - Country:US
Practice Address - Phone:217-351-8046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003750261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty