Basic Information
| Provider Information | |||||||||
| NPI: | 1275576035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN SPINE AND REHABILITATION SPECIALISTS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 VANDERBILT PARK DR | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282557776 | ||||||||
| FaxNumber: | 8282747855 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 VANDERBILT PARK DR | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282557776 | ||||||||
| FaxNumber: | 8282747855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | FLEMING | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8282557776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNTAIN NEUROSURGICAL & SPINE CENTER PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 134844 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 018CM | 01 | NC | BCBS NC PROVIDER # | OTHER | 2322706 | 01 | NC | MEDICARE PTAN | OTHER | 5903568 | 05 | NC | MEDICAID |