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General NPI Number Information
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NPI Number | 1548696446
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Entity Type | Organization
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Legal Business Name | MIDWEST PAIN CLINIC INTERVENTIONAL LLC
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Dates
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Enumeration Date | 09/24/2013
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Last Update Date | 02/17/2017
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Provider Practice Location Address
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Address Line | 350 COMMERCE SQ
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-3376
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Country | US
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Telephone | 219-872-9158
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Fax | 219-873-9196
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Provider Business Mailing Address
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Address Line | 350 COMMERCE SQ
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-3376
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Country | US
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Telephone | 219-872-9158
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Fax | 219-873-9196
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Authorized Official
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Title or Position | OWNER
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Name | PAUL C MADISON
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Credential | M.D.
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Telephone | 219-872-9158
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | 01031628A
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License Number State | IN
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