Provider Demographics
NPI:1962650218
Name:MIDWEST PAIN CLINIC
Entity Type:Organization
Organization Name:MIDWEST PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAIN MANAGEMENT SPECIALIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-812-9158
Mailing Address - Street 1:907 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3517
Mailing Address - Country:US
Mailing Address - Phone:219-812-9158
Mailing Address - Fax:219-873-9196
Practice Address - Street 1:907 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3517
Practice Address - Country:US
Practice Address - Phone:219-812-9158
Practice Address - Fax:219-873-9196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN036.066567261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain