Provider Demographics
NPI:1023278470
Name:INDIANA PAIN AND SPINE CLINIC CORPORATION
Entity type:Organization
Organization Name:INDIANA PAIN AND SPINE CLINIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMER
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-234-2191
Mailing Address - Street 1:6915 N FIR RD
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4754
Mailing Address - Country:US
Mailing Address - Phone:574-234-2191
Mailing Address - Fax:574-234-7720
Practice Address - Street 1:6915 N FIR RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4754
Practice Address - Country:US
Practice Address - Phone:574-234-2191
Practice Address - Fax:574-234-7720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059304A208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000576523OtherANTHEM
IN6711760001Medicare NSC
IN257550Medicare PIN