Provider Demographics
NPI:1841505302
Name:DESERT SPINE INSTITUTE PLLC
Entity type:Organization
Organization Name:DESERT SPINE INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:F
Authorized Official - Last Name:HERMENAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-247-9714
Mailing Address - Street 1:2851 S AVENUE B STE 2401
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7759
Mailing Address - Country:US
Mailing Address - Phone:928-247-9714
Mailing Address - Fax:928-247-9718
Practice Address - Street 1:2851 S AVENUE B
Practice Address - Street 2:SUITE 2401
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7726
Practice Address - Country:US
Practice Address - Phone:928-247-9714
Practice Address - Fax:928-247-9718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ541871Medicaid
Z140238Medicare PIN
AZ6460830001Medicare NSC