Provider Demographics
NPI:1629063797
Name:PAIN MANAGEMENT CENTER OF SOUTHERN INDIANA, INC.
Entity Type:Organization
Organization Name:PAIN MANAGEMENT CENTER OF SOUTHERN INDIANA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:TIWARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-333-7246
Mailing Address - Street 1:PO BOX 5635
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407-5635
Mailing Address - Country:US
Mailing Address - Phone:812-337-5003
Mailing Address - Fax:812-337-5010
Practice Address - Street 1:2920 MCINTYRE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-333-7246
Practice Address - Fax:812-333-4471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003765A261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100389270Medicaid
IN197890Medicare PIN
IN100389270Medicaid
IN1079250001Medicare NSC