Basic Information
| Provider Information | |||||||||
| NPI: | 1497391619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADISON SPINE SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 RIVER OAKS DR STE B103 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392327602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013211504 | ||||||||
| FaxNumber: | 6019326111 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 FOUNTAINS BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013211504 | ||||||||
| FaxNumber: | 6019326111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2019 | ||||||||
| LastUpdateDate: | 11/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6013211504 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.