MEDICARE: INDIANA PAIN AND SPINE CLINIC CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician	01059304A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000576523	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1023278470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA PAIN AND SPINE CLINIC CORPORATION

Provider Business Mailing Address
First Line	:	6915 N FIR RD
Second Line	:
City	:	GRANGER
State	:	IN
Zip	:	46530-4754
Country	:	US
Telephone Number	:	574-234-2191
Fax Number	:	574-234-7720

Provider Business Practice Location Address
First Line	:	6915 N FIR RD
Second Line	:
City	:	GRANGER
State	:	IN
Zip	:	46530-4754
Country	:	US
Telephone Number	:	574-234-2191
Fax Number	:	574-234-7720

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. AMER M KAZI
Credential	:	M.D.
Telephone Number	:	574-234-2191

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	02/25/2020

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Directions to “INDIANA PAIN AND SPINE CLINIC CORPORATION ” Practice Location

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