Provider Demographics
NPI:1316329071
Name:SOUTHERN SPINE INSTITUTE PLLC
Entity type:Organization
Organization Name:SOUTHERN SPINE INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BANISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-683-9251
Mailing Address - Street 1:PO BOX 260343
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75026-0343
Mailing Address - Country:US
Mailing Address - Phone:806-683-9251
Mailing Address - Fax:888-770-6360
Practice Address - Street 1:11970 N CENTRAL EXPY STE 450
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3787
Practice Address - Country:US
Practice Address - Phone:972-385-9898
Practice Address - Fax:888-770-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1856174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty