Healthcare Provider Details

I. General information

NPI: 1255506309
Provider Name (Legal Business Name): I-SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 FULMER RD
MISHAWAKA IN
46544-6911
US

IV. Provider business mailing address

615 FULMER RD
MISHAWAKA IN
46544-6911
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-2663
  • Fax: 574-252-5940
Mailing address:
  • Phone: 574-252-2663
  • Fax: 574-252-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MADHU RAO
Title or Position: CEO
Credential: DO
Phone: 574-252-2663