Provider Demographics
NPI:1720222862
Name:PAIN MANAGEMENT CENTER OF SOUTHERN INDIANA
Entity Type:Organization
Organization Name:PAIN MANAGEMENT CENTER OF SOUTHERN INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:TIWARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-944-7246
Mailing Address - Street 1:4330 S ROCKPORT RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-9765
Mailing Address - Country:US
Mailing Address - Phone:812-944-7246
Mailing Address - Fax:812-949-1538
Practice Address - Street 1:1919 STATE STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4929
Practice Address - Country:US
Practice Address - Phone:812-944-7246
Practice Address - Fax:812-949-1538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100389270Medicaid
IN547260Medicare PIN
IN1079250005Medicare NSC