Provider Demographics
NPI:1942563259
Name:SPINALCARE PHYSICAL MEDICINE LLC
Entity Type:Organization
Organization Name:SPINALCARE PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DETTMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-272-4100
Mailing Address - Street 1:114 N AVON AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8475
Mailing Address - Country:US
Mailing Address - Phone:317-272-4100
Mailing Address - Fax:317-272-4110
Practice Address - Street 1:114 N AVON AVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8475
Practice Address - Country:US
Practice Address - Phone:317-272-4100
Practice Address - Fax:317-272-4110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN111N00000X
208D00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1910Medicare PIN