Healthcare Provider Details

I. General information

NPI: 1033454012
Provider Name (Legal Business Name): RDK PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 CHARLESTOWN RD
NEW ALBANY IN
47150-2555
US

IV. Provider business mailing address

2580 CHARLESTOWN RD
NEW ALBANY IN
47150-2555
US

V. Phone/Fax

Practice location:
  • Phone: 812-941-8635
  • Fax: 812-941-8630
Mailing address:
  • Phone:
  • Fax: 812-941-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number02000860A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RICKEY D. KINZEY
Title or Position: SOLE MEMBER/OWNER
Credential: D.O.
Phone: 812-941-8635