Provider Demographics
NPI:1366761793
Name:PERFORMANCE SPINE & SPORTS SPECIALISTS, PA
Entity type:Organization
Organization Name:PERFORMANCE SPINE & SPORTS SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON-BETHEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-501-3796
Mailing Address - Street 1:PO BOX 38728
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27438-8728
Mailing Address - Country:US
Mailing Address - Phone:336-501-3796
Mailing Address - Fax:336-333-5477
Practice Address - Street 1:1507 WESTOVER TER STE B
Practice Address - Street 2:SUITE A
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7121
Practice Address - Country:US
Practice Address - Phone:336-501-3796
Practice Address - Fax:336-333-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909458Medicaid
NC5909458Medicaid
NCI46589Medicare UPIN