Healthcare Provider Details

I. General information

NPI: 1487239067
Provider Name (Legal Business Name): MIDWEST INNOVATIVE PAIN MANAGEMENT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 JOLIET ST STE 101
DYER IN
46311-1995
US

IV. Provider business mailing address

PO BOX 31
DYER IN
46311-0031
US

V. Phone/Fax

Practice location:
  • Phone: 219-235-3148
  • Fax:
Mailing address:
  • Phone: 219-440-0135
  • Fax: 833-523-9918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MAHER FATTOUH
Title or Position: OWNER
Credential: MD
Phone: 414-455-1153