Provider Demographics
NPI:1982648762
Name:INDIANA INTERVENTIONAL PAIN, LLC
Entity Type:Organization
Organization Name:INDIANA INTERVENTIONAL PAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SWOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:317-567-2180
Mailing Address - Street 1:PO BOX 3056
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3056
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:5445 E 16TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4869
Practice Address - Country:US
Practice Address - Phone:317-355-4358
Practice Address - Fax:317-567-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200530430Medicaid
INDE7729OtherRAILROAD MEDICARE
IN000000373172OtherANTHEM
IN200530430Medicaid