Provider Demographics
NPI:1407115884
Name:MICHIANA SPINE, SPORTS & OCCUPATIONAL REHAB, PC
Entity Type:Organization
Organization Name:MICHIANA SPINE, SPORTS & OCCUPATIONAL REHAB, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DREW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-252-4150
Mailing Address - Street 1:3740 EDISON LAKES PKWY
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3474
Mailing Address - Country:US
Mailing Address - Phone:574-252-4150
Mailing Address - Fax:574-252-4159
Practice Address - Street 1:2500 NILES RD STE 3
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3225
Practice Address - Country:US
Practice Address - Phone:574-252-4150
Practice Address - Fax:574-252-4159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070312208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty