1508220633 NPI number — INDIANA SPINE GROUP, PC

Table of content: (NPI 1508220633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508220633 NPI number — INDIANA SPINE GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA SPINE GROUP, PC
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:
1508220633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13225 N MERIDIAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-5480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-228-7000
Provider Business Mailing Address Fax Number:
317-228-2321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
747 E. COUNTY LINE RD.
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143-1082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-893-1960
Provider Business Practice Location Address Fax Number:
317-851-9728
Provider Enumeration Date:
04/05/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SIKAND
Authorized Official First Name:
HARDEEP
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
317-228-7000

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  50004386A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0117X , with the licence number: 50004386A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200359410 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000214063 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".