Basic Information
| Provider Information | |||||||||
| NPI: | 1376965376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED SPINE & PAIN MANAGEMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 THOMAS MOORE PKWY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594267246 | ||||||||
| FaxNumber: | 5136246900 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 THOMAS MOORE PKWY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594267246 | ||||||||
| FaxNumber: | 5136246900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2014 | ||||||||
| LastUpdateDate: | 05/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | MUKARRAM | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | DO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8594267246 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | KY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208VP0014X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.