Basic Information
| Provider Information | |||||||||
| NPI: | 1811401136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA SPINE & PAIN INSTITUTE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4411 WASHINGTON AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124377246 | ||||||||
| FaxNumber: | 8124027246 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 WASHINGTON AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126379861 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2017 | ||||||||
| LastUpdateDate: | 05/31/2019 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | MANSOOR | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8128032312 | ||||||||
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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 | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.