Provider Demographics
NPI:1942622477
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:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUKARRAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-619-3600
Mailing Address - Street 1:54 REMICK BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9168
Mailing Address - Country:US
Mailing Address - Phone:937-619-3600
Mailing Address - Fax:513-624-6900
Practice Address - Street 1:54 REMICK BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9168
Practice Address - Country:US
Practice Address - Phone:937-619-3600
Practice Address - Fax:513-624-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208VP0014X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6452140006Medicare NSC