Provider Demographics
NPI:1851494371
Name:NORTHWEST INDIANA SPINAL SURGERY, P.C.
Entity Type:Organization
Organization Name:NORTHWEST INDIANA SPINAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-738-2255
Mailing Address - Street 1:9235 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7046
Mailing Address - Country:US
Mailing Address - Phone:219-738-2255
Mailing Address - Fax:219-738-2060
Practice Address - Street 1:9235 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7046
Practice Address - Country:US
Practice Address - Phone:219-738-2255
Practice Address - Fax:219-738-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033705A207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100195070AMedicaid
IN605290Medicare PIN