1265644397 NPI number — INDIANA SPINE AND PAIN CENTER INC

Table of content: (NPI 1265644397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265644397 NPI number — INDIANA SPINE AND PAIN CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA SPINE AND PAIN CENTER INC
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:
6
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:
1265644397
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8202 CLEARVISTA PARKWAY
Provider Second Line Business Mailing Address:
SUITE 9 E
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46256-1457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-577-1800
Provider Business Mailing Address Fax Number:
317-577-1805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8202 CLEARVISTA PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 9 E
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46256-1457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-577-1800
Provider Business Practice Location Address Fax Number:
317-577-1805
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KINGMA
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
317-577-1800

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  01040487 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , with the licence number: 01040487A , 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)





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