Provider Demographics
NPI:1952531642
Name:EASTERN HEADACHE AND SPINE, PA
Entity Type:Organization
Organization Name:EASTERN HEADACHE AND SPINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-215-3067
Mailing Address - Street 1:498 A RED BANKS ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858
Mailing Address - Country:US
Mailing Address - Phone:252-215-3067
Mailing Address - Fax:
Practice Address - Street 1:498 A RED BANKS ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858
Practice Address - Country:US
Practice Address - Phone:252-215-3067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004003202084N0400X, 2084P2900X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1363XOtherBLUE CROSS BLUE SHIELD
NC891363XMedicaid
2027850BMedicare PIN