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General NPI Number Information
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NPI Number | 1578870879
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Entity Type | Organization
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Legal Business Name | COMPREHENSIVE PAIN REHAB OF SOUTHERN INDIANA LLC
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Dates
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Enumeration Date | 09/08/2010
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Last Update Date | 09/08/2010
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Provider Practice Location Address
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Address Line | 2920 MCINTIRE DRIVE SUITE 150B
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City | BLOOMINGTON
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State | IN
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Zip | 47403-4213
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Country | US
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Telephone | 812-333-7246
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Fax | 812-333-4471
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Provider Business Mailing Address
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Address Line | 2920 MCINTIRE DRIVE SUITE 150B
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City | BLOOMINGTON
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State | IN
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Zip | 47403-4213
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Country | US
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Telephone | 812-333-7246
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Fax | 812-333-4471
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Authorized Official
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Title or Position | OWNER
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Name | DERK FRASIER
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Credential |
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Telephone | 812-333-7246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State | IN
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