=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730447012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERVENTIONAL CLINICS OF AMERICA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2012
-----------------------------------------------------
Last Update Date | 08/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8300 BROADWAY SUITE A1
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-779-8346
-----------------------------------------------------
Fax | 925-380-3168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8300 BROADWAY SUITE A1
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-779-8346
-----------------------------------------------------
Fax | 925-380-3168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. VIVEK KUMAR AGRAWAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 408-460-4502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------