Provider Demographics
NPI:1255506309
Name:I-SPINE, LLC
Entity Type:Organization
Organization Name:I-SPINE, LLC
Other - Org Name:ORTHO & SPORTS CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MADHU
Authorized Official - Middle Name:
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-252-2663
Mailing Address - Street 1:615 FULMER RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6911
Mailing Address - Country:US
Mailing Address - Phone:574-252-2663
Mailing Address - Fax:574-252-5940
Practice Address - Street 1:615 FULMER RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-6911
Practice Address - Country:US
Practice Address - Phone:574-252-2663
Practice Address - Fax:574-252-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN256940Medicare PIN