Basic Information
| Provider Information | |||||||||
| NPI: | 1124526306 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA PAIN CENTERS-EVANSVILLE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4411 WASHINGTON AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126379861 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 WASHINGTON AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126379861 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2018 | ||||||||
| LastUpdateDate: | 01/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | MANSOOR | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3126379861 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.