1811401136 NPI number — INDIANA SPINE & PAIN INSTITUTE PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811401136 NPI number — INDIANA SPINE & PAIN INSTITUTE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA SPINE & PAIN INSTITUTE 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:
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:
1811401136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4411 WASHINGTON AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47714-0805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-437-7246
Provider Business Mailing Address Fax Number:
812-402-7246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4411 WASHINGTON AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47714-0805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-637-9861
Provider Business Practice Location Address Fax Number:
770-573-9513
Provider Enumeration Date:
11/22/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
MANSOOR
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-803-2312

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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