Provider Demographics
NPI:1104989458
Name:EASTERN NEUROSURGICAL AND SPINE ASSOCIATES, INC.
Entity type:Organization
Organization Name:EASTERN NEUROSURGICAL AND SPINE ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:DENNIE
Authorized Official - Last Name:MCKEITHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:252-752-5156
Mailing Address - Street 1:2325 STANTONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7534
Mailing Address - Country:US
Mailing Address - Phone:252-752-5156
Mailing Address - Fax:252-752-0399
Practice Address - Street 1:2325 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7534
Practice Address - Country:US
Practice Address - Phone:252-752-5156
Practice Address - Fax:252-752-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300351208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901516Medicaid
NC230158Medicare ID - Type UnspecifiedGROUP NUMBER