1538154604 NPI number — PAIN MANAGEMENT & SURGERY CENTER OF SOUTHERN INDIANA

Table of content: (NPI 1538154604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538154604 NPI number — PAIN MANAGEMENT & SURGERY CENTER OF SOUTHERN INDIANA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT & SURGERY CENTER OF SOUTHERN INDIANA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538154604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5635
Provider Second Line Business Mailing Address:
ATTN MARIA MITCHELL
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47407-5635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-824-5688
Provider Business Mailing Address Fax Number:
812-824-5692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2920 MCINTYRE DR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-4221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-333-7246
Provider Business Practice Location Address Fax Number:
812-333-4471
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TIWARI
Authorized Official First Name:
KAMAL
Authorized Official Middle Name:
KUMAR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
812-824-5688

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  61100223B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000098134 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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