Basic Information
| Provider Information | |||||||||
| NPI: | 1316971393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE INSTITUTE PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 E GRAY ST | ||||||||
| Address2: | # 900 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025847525 | ||||||||
| FaxNumber: | 5025890849 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E GRAY ST | ||||||||
| Address2: | # 900 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025847525 | ||||||||
| FaxNumber: | 5025890849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOCHERT | ||||||||
| AuthorizedOfficialFirstName: | TRINA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5025848002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | CM8616 | 01 | KY | MEDICARE RAILROAD | OTHER | 100020240A | 05 | IN | MEDICAID | 65917270 | 05 | KY | MEDICAID | 163722400 | 01 | US DEPT OF LABOR | OTHER | 2433673000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 36123 | 01 | KY | CIGNA | OTHER | 1054516 | 01 | KY | PASSPORT | OTHER |