Provider Demographics
NPI:1720031917
Name:ORTHOPEDIC AND SPINE SURGERY LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC AND SPINE SURGERY LLC
Other - Org Name:MIDWEST SPINE SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAVISHANKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VEDANTAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-983-3373
Mailing Address - Street 1:1050 REID PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1156
Mailing Address - Country:US
Mailing Address - Phone:765-983-3373
Mailing Address - Fax:765-983-3413
Practice Address - Street 1:1050 REID PKWY
Practice Address - Street 2:STE 100
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1156
Practice Address - Country:US
Practice Address - Phone:765-983-3373
Practice Address - Fax:765-983-3413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200455970AMedicaid
OH2524049Medicaid
OHDB4737Medicare PIN
IN210140Medicare PIN