Provider Demographics
NPI:1568444586
Name:INDIANA PAIN AND SPINE CARE
Entity Type:Organization
Organization Name:INDIANA PAIN AND SPINE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANOFF
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:317-837-1999
Mailing Address - Street 1:1100 SOUTHFIELD DR
Mailing Address - Street 2:SUITE 1330
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4498
Mailing Address - Country:US
Mailing Address - Phone:317-837-1999
Mailing Address - Fax:317-837-0233
Practice Address - Street 1:1100 SOUTHFIELD DR
Practice Address - Street 2:SUITE 1330
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-4498
Practice Address - Country:US
Practice Address - Phone:317-837-1999
Practice Address - Fax:317-837-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200496300AMedicaid
IN218940Medicare PIN