Basic Information
| Provider Information | |||||||||
| NPI: | 1982648762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA INTERVENTIONAL PAIN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3056 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Practice Location | |||||||||
| Address1: | 5445 E 16TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462184869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173554358 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 11/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | SWOFFORD | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3175672180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207LP2900X | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200530430 | 05 | IN | MEDICAID | DE7729 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000373172 | 01 | IN | ANTHEM | OTHER |