Provider Demographics
NPI:1932120912
Name:SOUTH EMERSON PAIN MANAGEMENT CENTER
Entity Type:Organization
Organization Name:SOUTH EMERSON PAIN MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-888-1051
Mailing Address - Street 1:8141 S EMERSON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8560
Mailing Address - Country:US
Mailing Address - Phone:317-888-1051
Mailing Address - Fax:317-888-1591
Practice Address - Street 1:8141 S EMERSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8560
Practice Address - Country:US
Practice Address - Phone:317-888-1051
Practice Address - Fax:317-888-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1052Medicare PIN