Healthcare Provider Details

I. General information

NPI: 1205041340
Provider Name (Legal Business Name): INDIANA BACK CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13450 N MERIDIAN ST STE 244
CARMEL IN
46032-1546
US

IV. Provider business mailing address

13450 N MERIDIAN ST STE 244
CARMEL IN
46032-1546
US

V. Phone/Fax

Practice location:
  • Phone: 317-846-4484
  • Fax: 317-571-2344
Mailing address:
  • Phone: 317-846-4484
  • Fax: 317-571-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number01039661
License Number StateIN

VIII. Authorized Official

Name: DR. JOHN A SHAY
Title or Position: OWNER
Credential: MD
Phone: 317-846-4484