Provider Demographics
NPI:1407975493
Name:MIDWEST SPINE INTERVENTIONALIST,LLC
Entity Type:Organization
Organization Name:MIDWEST SPINE INTERVENTIONALIST,LLC
Other - Org Name:INTERVENTIONAL SPINE & PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVEKANAND
Authorized Official - Middle Name:
Authorized Official - Last Name:MANOCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-619-0724
Mailing Address - Street 1:578 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9552
Mailing Address - Country:US
Mailing Address - Phone:937-619-0724
Mailing Address - Fax:937-619-0400
Practice Address - Street 1:578 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9552
Practice Address - Country:US
Practice Address - Phone:937-619-0724
Practice Address - Fax:937-619-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-087792208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9367991Medicare PIN