Provider Demographics
NPI:1912083957
Name:INTERNATIONAL SPINE SURGERY & PAIN INSTITURE PA
Entity Type:Organization
Organization Name:INTERNATIONAL SPINE SURGERY & PAIN INSTITURE PA
Other - Org Name:SPINE ARKANSAS INC PA
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:EUBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-931-0655
Mailing Address - Street 1:1513 MARKET PLACE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401
Mailing Address - Country:US
Mailing Address - Phone:870-931-0655
Mailing Address - Fax:870-931-0665
Practice Address - Street 1:1513 MARKET PLACE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-931-0655
Practice Address - Fax:870-931-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1177111N00000X
ARE2241207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C590Medicare ID - Type UnspecifiedCLINIC NUMBER