Provider Demographics
NPI:1689966434
Name:CORYDON PAIN MANAGEMENT CLINIC INC
Entity Type:Organization
Organization Name:CORYDON PAIN MANAGEMENT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:TORNATORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-767-9439
Mailing Address - Street 1:2230 EDSEL LN NW STE 1
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2136
Mailing Address - Country:US
Mailing Address - Phone:812-734-0303
Mailing Address - Fax:812-225-5145
Practice Address - Street 1:2230 EDSEL LN NW STE 1
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2136
Practice Address - Country:US
Practice Address - Phone:812-734-0303
Practice Address - Fax:812-225-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201058650AMedicaid
IN201058650AMedicaid