Basic Information
| Provider Information | |||||||||
| NPI: | 1790881746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED SPINE & PAIN MANAGEMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7691 5 MILE RD | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452302163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136247246 | ||||||||
| FaxNumber: | 5136246900 | ||||||||
| Practice Location | |||||||||
| Address1: | 7691 5 MILE RD | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452304348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136247246 | ||||||||
| FaxNumber: | 5136246900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 06/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | MUKARRAM | ||||||||
| AuthorizedOfficialMiddleName: | ALI | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5136247246 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | OH | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363LA2200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 208VP0000X | 34.008823 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | 34.008823 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2679703 | 05 | OH | MEDICAID | 296827989001 | 01 | MEDICAL MUTUAL | OTHER | 7100315340 - MD GRP | 05 | KY | MEDICAID | 617433400 | 01 | OH | DEPT OF LABOR - MD | OTHER | 617465100 | 01 | OH | DEPT. OF LABOR - APRN | OTHER | 150730 | 01 | OH | NATIONWIDE | OTHER | 6226080 | 01 | OH | CIGNA | OTHER | 7100287020 -NP GROUP | 05 | KY | MEDICAID | 317306 | 01 | OH | AMERIGROUP | OTHER | 7100240230 MD GRP # | 05 | OH | MEDICAID | 000000488997 | 01 | OH | ANTHEM | OTHER | 617433404 | 01 | OH | US DEPT OF LABOR - EATON OFFICE | OTHER | 617433403 | 01 | OH | US DEPT OF LABOR - SPRINGFIELD OFFICE | OTHER | 617433406 | 01 | OH | US DEPT OF LABOR - SPRINGBORO OFFICE | OTHER | P00415701 | 01 | OH | RAILROAD MEDICARE | OTHER |