Provider Demographics
NPI:1285925404
Name:ARIZONA BRAIN AND SPINE TRAUMA PLLC
Entity type:Organization
Organization Name:ARIZONA BRAIN AND SPINE TRAUMA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:R
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-663-7346
Mailing Address - Street 1:9250 N 3RD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2437
Mailing Address - Country:US
Mailing Address - Phone:602-266-2927
Mailing Address - Fax:602-266-2927
Practice Address - Street 1:9250 N 3RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2437
Practice Address - Country:US
Practice Address - Phone:602-266-2927
Practice Address - Fax:602-266-2927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44305207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty