Basic Information
| Provider Information | |||||||||
| NPI: | 1154745263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVASPINE PAIN INSTITUTE, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5068 | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853765068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237774747 | ||||||||
| FaxNumber: | 6237774748 | ||||||||
| Practice Location | |||||||||
| Address1: | 14300 W GRANITE VALLEY DR STE A1 | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853755797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237774747 | ||||||||
| FaxNumber: | 6237774748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2014 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | CLIFFORD | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6237774747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 42990 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 42990 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 2081P2900X | 42990 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X | 42990 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 332B00000X | 42990 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208VP0000X | 42990 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 506835 | 05 | AZ | MEDICAID |