Basic Information
| Provider Information | |||||||||
| NPI: | 1609202704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE INSTITUTE OF TEXAS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11970 N CENTRAL EXPY | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752433768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724994280 | ||||||||
| FaxNumber: | 2142428980 | ||||||||
| Practice Location | |||||||||
| Address1: | 11970 N CENTRAL EXPY | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752433768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724994280 | ||||||||
| FaxNumber: | 2142428980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2013 | ||||||||
| LastUpdateDate: | 09/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | BANISTER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9724994280 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 174400000X | J1856 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.