Basic Information
| Provider Information | |||||||||
| NPI: | 1295370419 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERVENTIONAL PAIN & SPINE SPECIALISTS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VITALITY PAIN CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7145 E VIRGINIA ST STE 2000 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477159147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129627894 | ||||||||
| FaxNumber: | 8124766162 | ||||||||
| Practice Location | |||||||||
| Address1: | 7145 E VIRGINIA ST STE 1000 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477159147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124766166 | ||||||||
| FaxNumber: | 8124766162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2019 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | TAMIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8129627894 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 15D2192364 | 01 | IN | CLIA | OTHER |