Provider Demographics
NPI:1811401136
Name:INDIANA SPINE & PAIN INSTITUTE PC
Entity Type:Organization
Organization Name:INDIANA SPINE & PAIN INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANSOOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-803-2312
Mailing Address - Street 1:4411 WASHINGTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0805
Mailing Address - Country:US
Mailing Address - Phone:812-437-7246
Mailing Address - Fax:812-402-7246
Practice Address - Street 1:4411 WASHINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0805
Practice Address - Country:US
Practice Address - Phone:312-637-9861
Practice Address - Fax:770-573-9513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty