Organization
BACK & SPINE MEDICAL INSTITUTE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RANDY JOHNSON (MD/OWNER)
(314) 781-8082
Entity
Organization
Contact information
Practice address
5300 N ILLINOIS ST, FAIRVIEW HEIGHTS, IL 62208-3500
(618) 222-2222
Mailing address
1836 LACKLAND HILL PKWY, SAINT LOUIS, MO 63146-3572
(314) 989-0300
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DE2495
RR MEDICARE GROUP#
IL
Enumeration date
09/20/2006
Last updated
11/16/2007
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