Provider Demographics
NPI:1568642601
Name:INTERVENTIONAL SPINE AND PAIN CENTERS, LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL SPINE AND PAIN CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-513-2333
Mailing Address - Street 1:8317 CALUMET AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1737
Mailing Address - Country:US
Mailing Address - Phone:219-513-2333
Mailing Address - Fax:219-513-2334
Practice Address - Street 1:8317 CALUMET AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1737
Practice Address - Country:US
Practice Address - Phone:219-513-2333
Practice Address - Fax:219-513-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062605A207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INI68319Medicare UPIN