Provider Demographics
NPI:1982207478
Name:INTERVENTIONAL PAIN & SPINE SPECIALISTS LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN & SPINE SPECIALISTS LLC
Other - Org Name:VITALITY PAIN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TAMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-962-7894
Mailing Address - Street 1:7145 E VIRGINIA ST STE 2000
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-9147
Mailing Address - Country:US
Mailing Address - Phone:812-962-7894
Mailing Address - Fax:
Practice Address - Street 1:7145 E VIRGINIA ST STE 1000
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-9147
Practice Address - Country:US
Practice Address - Phone:812-476-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300051654Medicaid