Provider Demographics
NPI:1790881746
Name:ADVANCED SPINE & PAIN MANAGEMENT INC
Entity Type:Organization
Organization Name:ADVANCED SPINE & PAIN MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUKARRAM
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:513-624-7246
Mailing Address - Street 1:7691 5 MILE RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-2163
Mailing Address - Country:US
Mailing Address - Phone:513-624-7246
Mailing Address - Fax:513-624-6900
Practice Address - Street 1:7691 5 MILE RD
Practice Address - Street 2:SUITE 10
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4348
Practice Address - Country:US
Practice Address - Phone:513-624-7246
Practice Address - Fax:513-624-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008823208VP0000X, 208VP0014X
OH332B00000X
363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2679703Medicaid
296827989001OtherMEDICAL MUTUAL
KY7100315340 - MD GRPMedicaid
OH617433400OtherDEPT OF LABOR - MD
OH617465100OtherDEPT. OF LABOR - APRN
OH150730OtherNATIONWIDE
OH6226080OtherCIGNA
KY7100287020 -NP GROUPMedicaid
OH317306OtherAMERIGROUP
OH7100240230 MD GRP #Medicaid
OH000000488997OtherANTHEM
OH617433404OtherUS DEPT OF LABOR - EATON OFFICE
OH617433403OtherUS DEPT OF LABOR - SPRINGFIELD OFFICE
OH617433406OtherUS DEPT OF LABOR - SPRINGBORO OFFICE
OHP00415701OtherRAILROAD MEDICARE
OH6226080OtherCIGNA
KY7100315340 - MD GRPMedicaid
KY7100315340 - MD GRPMedicaid
OH7100240230 MD GRP #Medicaid
OH6452140001Medicare NSC