Basic Information
| Provider Information | |||||||||
| NPI: | 1801349386 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL PAIN MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2105 ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463832907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194767246 | ||||||||
| FaxNumber: | 2194761713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1924 45TH STREET | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194767246 | ||||||||
| FaxNumber: | 2194761713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2016 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | PURANIK | ||||||||
| AuthorizedOfficialFirstName: | UJWALA | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2194767246 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTERVENTIONAL PAIN MANAGEMENT, LLC | ||||||||
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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.