Provider Demographics
NPI:1962944272
Name:AXIS SPINE PLLC
Entity type:Organization
Organization Name:AXIS SPINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-457-4208
Mailing Address - Street 1:1641 E POLSTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7852
Mailing Address - Country:US
Mailing Address - Phone:208-457-4208
Mailing Address - Fax:208-457-4197
Practice Address - Street 1:1641 E POLSTON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7852
Practice Address - Country:US
Practice Address - Phone:208-457-4208
Practice Address - Fax:208-457-4197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1962944272Medicaid
ID20011051Medicare Oscar/Certification