NPIMap

Organization Active NPI

Advanced Spine and Pain LLC

  • Pain Medicine (Physical Medicine & Rehabilitation) Physician
  • Mesa, AZ
National Provider Identifier
1629679923
Registry record updated Jan 20, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianTaxonomy code 2081P2900X
Legal business name
ADVANCED SPINE AND PAIN LLC
Practice address
4566 E Inverness Ave Ste 205
Mesa, AZ 85206-4634
Phone
(480) 640-0513
NPI assigned
Nov 3, 2020
Last updated
Jan 20, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 20, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jarrett Michael Leathem
Title
MD, Owner
Phone
(860) 670-2412

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine (Anesthesiology) Physician 207LP2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician 2081P2900X Primary
Pain Medicine Physician 208VP0000X
Interventional Pain Medicine Physician 208VP0014X
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X

Addresses

Primary practice location

4566 E Inverness Ave Ste 205
Mesa, AZ 85206-4634

Mailing address

4566 E Inverness Ave Ste 205
Mesa, AZ 85206-4634
Phone (480) 640-0513

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201229002585 AZ DME Supplier - Physician - Anesthesiology 0941610075 Practice locations: Mesa, AZ

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
03D2207431Advanced Spine and Pain, LLC4566 E Inverness Ave Ste 205, Mesa, AZ 85206Certificate of waiverDec 27, 2026

National Provider Directory

National Provider Directory
Tax ID family
Advanced Spine and Pain LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4566 E Inverness Ave
Ste 205
Mesa, AZ 85206
Phone (480) 640-0513

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1604361600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611100800000",
    "number": "1629679923",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4566 E INVERNESS AVE STE 205",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852064634",
            "telephone_number": "480-640-0513"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4566 E INVERNESS AVE STE 205",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852064634",
            "telephone_number": "480-640-0513"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADVANCED SPINE AND PAIN LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-11-03",
        "last_updated": "2021-01-20",
        "certification_date": "2021-01-20",
        "status": "A",
        "authorized_official_last_name": "LEATHEM",
        "authorized_official_first_name": "JARRETT",
        "authorized_official_middle_name": "MICHAEL",
        "authorized_official_title_or_position": "MD, OWNER",
        "authorized_official_telephone_number": "860-670-2412"
    },
    "taxonomies": [
        {
            "code": "207LP2900X",
            "taxonomy_group": "",
            "desc": "Anesthesiology, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2081P2900X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "208VP0000X",
            "taxonomy_group": "",
            "desc": "Pain Medicine, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0014X",
            "taxonomy_group": "",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mesa, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 20, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.