Provider Demographics
NPI:1952394603
Name:MDRS SPINE & SPORT, INC
Entity Type:Organization
Organization Name:MDRS SPINE & SPORT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-264-1417
Mailing Address - Street 1:3760 CONVOY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3743
Mailing Address - Country:US
Mailing Address - Phone:888-208-8526
Mailing Address - Fax:858-751-0901
Practice Address - Street 1:3760 CONVOY STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3743
Practice Address - Country:US
Practice Address - Phone:858-573-9368
Practice Address - Fax:858-874-0582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Multi-Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1073699674OtherNPI
CA1396059713OtherNPI
CADU462ZMedicare PIN
CAWPT29262BMedicare PIN
CA1932419876OtherNPI
CA1750344131OtherNPI
CA1326361247OtherNPI
CA1598843443OtherNPI
CA1336103878OtherNPI
CA1003879057OtherNPI
CA1972810042OtherNPI
CADH525ZMedicare PIN
CAWPT28039CMedicare PIN
CA1558676825OtherNPI
CA1962725879OtherNPI
CADK315ZMedicare PIN
CAWPT33811AMedicare PIN
CAWPT34244AMedicare PIN
CA1578526950OtherNPI
CA1841253721OtherNPI
CAWOT243BMedicare ID - Type UnspecifiedA LUDWIG
CAW15369Medicare ID - Type UnspecifiedGROUP ID
CADA887YMedicare PIN
CADP384ZMedicare PIN
CAWPT25572AMedicare PIN
CAWPT32643AMedicare PIN
CA1003934381OtherNPI
CA1932309200OtherNPI
CA1952446650OtherNPI
CA1447215397OtherNPI
CADG892ZMedicare PIN
CADR273ZMedicare PIN
CAWPT33505AMedicare PIN
CA1013221464OtherNPI
CA1194727305OtherNPI
CA1558324509OtherNPI
CAWC20677IMedicare ID - Type UnspecifiedV MOONEY
CACZ250ZMedicare PIN
CAWPT25572Medicare PIN