Basic Information
| Provider Information | |||||||||
| NPI: | 1720028558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT SPINE SPECIALISTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16934 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275166934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194422407 | ||||||||
| FaxNumber: | 9199676647 | ||||||||
| Practice Location | |||||||||
| Address1: | 3480 WAKE FOREST RD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197814541 | ||||||||
| FaxNumber: | 9197814812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | BENTLEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | GREGORY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9197814541 | ||||||||
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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 | 208VP0000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5902775 | 05 | NC | MEDICAID | 017P7 | 01 | NC | BLUE CROSS/BLUE SHIELD | OTHER |