Basic Information
| Provider Information | |||||||||
| NPI: | 1215931910 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA SPINE & NEUROSURGERY CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25370 | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288131370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282557776 | ||||||||
| FaxNumber: | 8282558794 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 VANDERBILT PARK DR | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282557776 | ||||||||
| FaxNumber: | 8282747855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOOMIS | ||||||||
| AuthorizedOfficialFirstName: | RALPH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8282557776 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2084N0400X | 39607 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207T00000X | 39607 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8902247 | 05 | NC | MEDICAID |