Provider Demographics
NPI:1215354972
Name:ISPINE SPORTS MEDICINE AND PAIN MANAGEMENT, PA
Entity type:Organization
Organization Name:ISPINE SPORTS MEDICINE AND PAIN MANAGEMENT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-969-2784
Mailing Address - Street 1:2220 CANTON ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-5923
Mailing Address - Country:US
Mailing Address - Phone:214-403-8402
Mailing Address - Fax:
Practice Address - Street 1:2220 CANTON ST
Practice Address - Street 2:SUITE 211
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-5923
Practice Address - Country:US
Practice Address - Phone:214-403-8402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8869207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty