Basic Information
| Provider Information | |||||||||
| NPI: | 1073607875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM NEUROSURGICAL SPECIALISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 HOSPITAL BLVD | ||||||||
| Address2: | STE 310 | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706649600 | ||||||||
| FaxNumber: | 7706649856 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 HOSPITAL BLVD | ||||||||
| Address2: | STE 310 | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706649600 | ||||||||
| FaxNumber: | 7706649856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 06/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | DISCH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7706649600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 300025035E | 05 | GA | MEDICAID |