Healthcare Provider Details

I. General information

NPI: 1982648762
Provider Name (Legal Business Name): INDIANA INTERVENTIONAL PAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 E 16TH ST
INDIANAPOLIS IN
46218-4869
US

IV. Provider business mailing address

PO BOX 3056
INDIANAPOLIS IN
46206-3056
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-4358
  • Fax: 317-567-2191
Mailing address:
  • Phone: 317-567-2180
  • Fax: 317-567-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: JOHN B SWOFFORD
Title or Position: PRESIDENT-OWNER
Credential: D.O.
Phone: 317-567-2180