Healthcare Provider Details

I. General information

NPI: 1568444586
Provider Name (Legal Business Name): INDIANA PAIN AND SPINE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHFIELD DR SUITE 1330
PLAINFIELD IN
46168-4498
US

IV. Provider business mailing address

1100 SOUTHFIELD DR SUITE 1330
PLAINFIELD IN
46168-4498
US

V. Phone/Fax

Practice location:
  • Phone: 317-837-1999
  • Fax: 317-837-0233
Mailing address:
  • Phone: 317-837-1999
  • Fax: 317-837-0233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200496300A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name: DR. VAN EVANOFF JR.
Title or Position: OWNER
Credential: M.D.
Phone: 317-837-1999