Provider Demographics
NPI:1205041340
Name:INDIANA BACK CENTER PC
Entity Type:Organization
Organization Name:INDIANA BACK CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-846-4484
Mailing Address - Street 1:13450 N MERIDIAN ST
Mailing Address - Street 2:STE 244
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1546
Mailing Address - Country:US
Mailing Address - Phone:317-846-4484
Mailing Address - Fax:317-571-2344
Practice Address - Street 1:13450 N MERIDIAN ST
Practice Address - Street 2:STE 244
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1546
Practice Address - Country:US
Practice Address - Phone:317-846-4484
Practice Address - Fax:317-571-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039661207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1255375994OtherPHYSICIAN INDIVIDUAL NPI
IN314010Medicare ID - Type Unspecified