Provider Demographics
NPI:1689981979
Name:COMPREHENSIVE PAIN REHAB OF SOUTHERN INDIANA LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE PAIN REHAB OF SOUTHERN INDIANA LLC
Other - Org Name:PAIN MANAGEMENT SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DERK
Authorized Official - Middle Name:
Authorized Official - Last Name:FRASIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-333-7246
Mailing Address - Street 1:8802 S. MADISON AVENUE
Mailing Address - Street 2:SUITE D
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6400
Mailing Address - Country:US
Mailing Address - Phone:812-333-7246
Mailing Address - Fax:812-889-6720
Practice Address - Street 1:8802 S. MADISON AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6400
Practice Address - Country:US
Practice Address - Phone:812-333-7246
Practice Address - Fax:812-889-6720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207L00000X, 208VP0000X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty