Provider Demographics
NPI:1699700195
Name:INTERVENTIONAL SPINE PAIN CONSULTANTS, PA
Entity type:Organization
Organization Name:INTERVENTIONAL SPINE PAIN CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:M
Authorized Official - Last Name:WITHERELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-478-7001
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-0947
Mailing Address - Country:US
Mailing Address - Phone:717-263-5562
Mailing Address - Fax:717-263-1566
Practice Address - Street 1:774 CHRISTIANA RD
Practice Address - Street 2:STE 111
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4236
Practice Address - Country:US
Practice Address - Phone:302-478-7001
Practice Address - Fax:302-478-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE200044870Medicaid
DEG01138Medicare ID - Type Unspecified