Provider Demographics
NPI:1861542953
Name:ADVANCED MICROSURGERY OF THE SPINE, P.A.
Entity type:Organization
Organization Name:ADVANCED MICROSURGERY OF THE SPINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHARTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-217-7520
Mailing Address - Street 1:P.O. BOX 1322
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-1322
Mailing Address - Country:US
Mailing Address - Phone:972-991-9950
Mailing Address - Fax:972-991-4026
Practice Address - Street 1:1341 W. MOCKINGBIRD LN
Practice Address - Street 2:MOCKINGBIRD TOWERS, SUITE 710E
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6913
Practice Address - Country:US
Practice Address - Phone:214-217-7520
Practice Address - Fax:214-217-7530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6344174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137748302Medicaid
TXDC0230OtherRR MEDICARE
TX094847301Medicaid
TX00MT02Medicare ID - Type Unspecified
TX137748302Medicaid
TXC23366Medicare UPIN