Basic Information
| Provider Information | |||||||||
| NPI: | 1689085193 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AXIS BRAIN AND BACK INSTITUTE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 E STATE HIGHWAY 114 STE 100 | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760925251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175027411 | ||||||||
| FaxNumber: | 8175027412 | ||||||||
| Practice Location | |||||||||
| Address1: | 9525 N BEACH ST STE 405 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762446438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175027411 | ||||||||
| FaxNumber: | 8175027412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2014 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | ARYAN | ||||||||
| AuthorizedOfficialFirstName: | SAEID | ||||||||
| AuthorizedOfficialMiddleName: | ESMAEILY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8175027411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | P9148 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00E4E2 | 01 | TX | BCBS | OTHER | 7273750001 | 01 | MEDICARE NSC | OTHER | 341501001 | 05 | TX | MEDICAID |