Provider Demographics
NPI:1265644397
Name:INDIANA SPINE AND PAIN CENTER INC
Entity Type:Organization
Organization Name:INDIANA SPINE AND PAIN CENTER INC
Other - Org Name:INDIANA LASER SPINE CENTER INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:R
Authorized Official - Last Name:KINGMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-577-1800
Mailing Address - Street 1:8202 CLEARVISTA PARKWAY
Mailing Address - Street 2:SUITE 9 E
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1457
Mailing Address - Country:US
Mailing Address - Phone:317-577-1800
Mailing Address - Fax:317-577-1805
Practice Address - Street 1:8202 CLEARVISTA PARKWAY
Practice Address - Street 2:SUITE 9 E
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1457
Practice Address - Country:US
Practice Address - Phone:317-577-1800
Practice Address - Fax:317-577-1805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040487261QM2500X
IN01040487A261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE87841Medicare UPIN