Healthcare Provider Details

I. General information

NPI: 1639164700
Provider Name (Legal Business Name): COMPREHENSIVE SPINE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 W COTA DR
BLOOMINGTON IN
47403-4217
US

IV. Provider business mailing address

PO BOX 5637 ATTN: MARIA MITCHELL
BLOOMINGTON IN
47407-5637
US

V. Phone/Fax

Practice location:
  • Phone: 812-337-0210
  • Fax: 812-337-0211
Mailing address:
  • Phone: 812-824-5688
  • Fax: 812-824-5692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number50004448A
License Number StateIN

VIII. Authorized Official

Name: KAMAL KUMAR TIWARI
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 812-333-7246