Basic Information
| Provider Information | |||||||||
| NPI: | 1154075562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE & EXTREMITIES CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
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| City: | OSCEOLA MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166660068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145779385 | ||||||||
| FaxNumber: | 8143396165 | ||||||||
| Practice Location | |||||||||
| Address1: | 457 S 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLARION | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162146011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142275855 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2022 | ||||||||
| LastUpdateDate: | 02/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLS | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8145779385 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
No ID Information.