Basic Information
| Provider Information | |||||||||
| NPI: | 1609204338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL SPINE & PAIN MANAGEMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 274 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843213915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357531600 | ||||||||
| FaxNumber: | 4357539521 | ||||||||
| Practice Location | |||||||||
| Address1: | 5801 S FASHION BLVD STE 180 | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841078135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012627246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2013 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | GARG | ||||||||
| AuthorizedOfficialFirstName: | VIKAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8012627246 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.