Provider Demographics
NPI:1871936294
Name:COLUMBIA MEDICAL SPORT & SPINE LLC
Entity type:Organization
Organization Name:COLUMBIA MEDICAL SPORT & SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VAUGHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DABBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-599-6846
Mailing Address - Street 1:8600 SNOWDEN RIVER PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-1982
Mailing Address - Country:US
Mailing Address - Phone:410-720-5555
Mailing Address - Fax:410-381-4653
Practice Address - Street 1:8600 SNOWDEN RIVER PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-1982
Practice Address - Country:US
Practice Address - Phone:410-720-5555
Practice Address - Fax:410-381-4653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051586208D00000X
332B00000X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD288453Medicare PIN