MEDICARE: PAIN MANAGEMENT SPECIALISTS LLC

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	261QP3300X	Pain Clinic/Center		IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DE2009	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000388635	OTHER	IN	ANTHEM
4	90001240	OTHER	IN	BCBS IL

General Provider Information

NPI Number	:	1881693562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MANAGEMENT SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	8840 CALUMET AVE
Second Line	:	SUITE 103
City	:	MUNSTER
State	:	IN
Zip	:	46321-4037
Country	:	US
Telephone Number	:	219-836-7246
Fax Number	:	219-836-6454

Provider Business Practice Location Address
First Line	:	8840 CALUMET AVE
Second Line	:	SUITE 103
City	:	MUNSTER
State	:	IN
Zip	:	46321-4037
Country	:	US
Telephone Number	:	219-836-7246
Fax Number	:	219-836-6454

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	SHANU KONDAMURI
Credential	:	M.D.
Telephone Number	:	219-836-7246

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	12/15/2011

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Directions to “PAIN MANAGEMENT SPECIALISTS LLC ” Practice Location

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