Basic Information
Provider Information | |||||||||
NPI: | 1902889173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAYNE | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7232 | ||||||||
Address2: | DEPT 165 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462077232 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175672180 | ||||||||
FaxNumber: | 3175672191 | ||||||||
Practice Location | |||||||||
Address1: | 2001 W 86TH ST | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462601902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175672180 | ||||||||
FaxNumber: | 3175672191 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2005 | ||||||||
LastUpdateDate: | 12/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01036287 | IN | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 01036287 | IN | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 100131370 | 05 | IN |   | MEDICAID |