Provider Demographics
NPI:1992985394
Name:EAST TEXAS SPINE INSTITUTE, PA
Entity type:Organization
Organization Name:EAST TEXAS SPINE INSTITUTE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RITESH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PRASAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-593-9999
Mailing Address - Street 1:PO BOX 130940
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0940
Mailing Address - Country:US
Mailing Address - Phone:903-593-9999
Mailing Address - Fax:903-526-4239
Practice Address - Street 1:3110 PARK CENTER DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9215
Practice Address - Country:US
Practice Address - Phone:903-593-9999
Practice Address - Fax:903-526-4239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1283208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty