Basic Information
| Provider Information | |||||||||
| NPI: | 1639841844 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERVENTIONAL PAIN & SPINE SPECIALISTS LLC | ||||||||
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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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 279 KINGS DAUGHTERS DR STE 100B | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406016563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023522530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | TAMIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8129627894 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 18D1082239 | 01 | KY | CLIA | OTHER |