Basic Information
| Provider Information | |||||||||
| NPI: | 1821014580 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED INTERVENTIONAL PAIN CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 N GRANVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473032110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 613 W LINCOLN RD STE A | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653193522 | ||||||||
| FaxNumber: | 7654506161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | SRINIVASAN | ||||||||
| AuthorizedOfficialFirstName: | PATTANAM | ||||||||
| AuthorizedOfficialMiddleName: | DORAI | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7658910721 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200532650A | 05 | IN | MEDICAID |