Provider Demographics
NPI:1912174418
Name:ST. ANTHONY'S SPINE & JOINT INSTITUTE, P.C.
Entity Type:Organization
Organization Name:ST. ANTHONY'S SPINE & JOINT INSTITUTE, P.C.
Other - Org Name:SPORTS & SPINAL REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:D'SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-842-2447
Mailing Address - Street 1:804 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-5829
Mailing Address - Country:US
Mailing Address - Phone:312-842-2447
Mailing Address - Fax:
Practice Address - Street 1:804 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5829
Practice Address - Country:US
Practice Address - Phone:312-842-2447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060009430261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center