Basic Information
| Provider Information | |||||||||
| NPI: | 1073920732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINIMAL ACCESS SPINE TECHNOLOGY | ||||||||
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| OtherOrganizationName: | EBOS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1651 | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775321651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814627684 | ||||||||
| FaxNumber: | 8888325078 | ||||||||
| Practice Location | |||||||||
| Address1: | 4582 KINGWOOD DR | ||||||||
| Address2: | SUITE 187 | ||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773452639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814627684 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2014 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | VADHEIM | ||||||||
| AuthorizedOfficialFirstName: | COLIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7132317720 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Electrodiagnostic Medicine |
No ID Information.