Advanced Spine and Pain LLC
Organization Active NPI Interventional Pain Medicine Physician · Goodyear, AZ
NPI 1366048860 · NPPES record last updated Jan 20, 2021
Key facts
- NPI
- 1366048860
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Interventional Pain Medicine Physician 208VP0014X
- Legal business name
- ADVANCED SPINE AND PAIN LLC
- Practice address
- 13555 W McDowell Rd Ste 207
Goodyear, AZ 85395-2628 - Phone
- (480) 573-0130
- NPI assigned
- Dec 9, 2020
- Organization subpart
- No
Authorized official
- Name
- Jarrett Michael Leathem
- Title
- Owner
- Phone
- (480) 573-0130
Other NPIs with the same Medicare PAC ID 5
Corporate family (same tax ID) 4
Practitioners 30
-
Jarrett Michael Leathem, D.O.
-
Steven Adler, PA-C
-
Jawad Arshad, MD
-
Marybeth Barcome, FNP
-
David Gordon Currie, M.D.
-
Alexander Dydyk, DO
-
Marc Lewis Eckhauser, M.D.
-
Drew C Hunter, M.D.
-
Mark A. Kallgren, MD
-
Stephen Jeremy Kominsky, D.P.M.
-
Jeffrey Krause, MD
-
Timothy A Luke, M.D.
-
Vikram Mayuran, M.D.
-
Peter McCunniff, MD
-
Lauren Katherine Mills, AGACNP
-
David Carlos Morales, M.D.
-
Roy O'Neil, DO
-
Renee Teresa Oroc, FNP-C
-
Scott R Schalkle, CRNA
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 03D2207430 | Advanced Spine and Pain, LLC | Certificate of waiver | Dec 27, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20201229002697 | AZ | DME Supplier - Physician - Anesthesiology | 0941610075 | Practice locations: Goodyear, AZ |
National Provider Directory
- Tax ID family
- Advanced Spine and Pain LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Anesthesiology Physician |
207L00000X | |||
| Pain Medicine (Physical Medicine & Rehabilitation) Physician |
2081P2900X | |||
| Pain Medicine Physician |
208VP0000X | |||
| Interventional Pain Medicine Physician |
208VP0014X | Yes | ||
| Physician Assistant |
363A00000X | |||
| Nurse Practitioner |
363L00000X |
Addresses
Primary practice location
13555 W McDowell Rd Ste 207
Goodyear, AZ 85395-2628
Mailing address
13555 W McDowell Rd Ste 207
Goodyear, AZ 85395-2628
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All providers in Goodyear, AZ · Interventional Pain Medicine Physician in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 20, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.