Basic Information
| Provider Information | |||||||||
| NPI: | 1316281967 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CORE INSTITUTE SPINE CENTER GILBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2680 S VAL VISTA DR | ||||||||
| Address2: | BUILDING 9, SUITE 146 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852952152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 2680 S VAL VISTA DR | ||||||||
| Address2: | BUILDING 9, SUITE 146 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852952152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2012 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | SIMON | ||||||||
| AuthorizedOfficialFirstName: | JOCELYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6234743427 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CORE INSTITUT E | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 341246 | 05 | AZ | MEDICAID |