Provider Demographics
NPI:1033454012
Name:RDK PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:RDK PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KINZEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-941-8635
Mailing Address - Street 1:2580 CHARLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:812-941-8630
Practice Address - Street 1:2580 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2555
Practice Address - Country:US
Practice Address - Phone:812-941-8635
Practice Address - Fax:812-941-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000860A207LP2900X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100446040Medicaid
IN000000368855OtherRKA ANTHEM
IN000000368845OtherRKP ANTHEM
IN000000368855OtherRKA ANTHEM
INE35247Medicare UPIN
IN100446040Medicaid