Healthcare Provider Details

I. General information

NPI: 1265644397
Provider Name (Legal Business Name): INDIANA SPINE AND PAIN CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 CLEARVISTA PARKWAY SUITE 9 E
INDIANAPOLIS IN
46256-1457
US

IV. Provider business mailing address

8202 CLEARVISTA PARKWAY SUITE 9 E
INDIANAPOLIS IN
46256-1457
US

V. Phone/Fax

Practice location:
  • Phone: 317-577-1800
  • Fax: 317-577-1805
Mailing address:
  • Phone: 317-577-1800
  • Fax: 317-577-1805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number01040487
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number01040487A
License Number StateIN

VIII. Authorized Official

Name: DR. PHILLIP R. KINGMA
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 317-577-1800