Provider Demographics
NPI:1487984100
Name:INDIANA SPINE SPECIALTY, LLC
Entity type:Organization
Organization Name:INDIANA SPINE SPECIALTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:SASSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-228-7000
Mailing Address - Street 1:13225 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5480
Mailing Address - Country:US
Mailing Address - Phone:317-228-7000
Mailing Address - Fax:317-228-9029
Practice Address - Street 1:13225 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5480
Practice Address - Country:US
Practice Address - Phone:317-228-7000
Practice Address - Fax:317-228-9029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN265630Medicare PIN