=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881081552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AAPOLO SPINE AND PAIN MANAGEMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2015
-----------------------------------------------------
Last Update Date | 10/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4215 N 210 E
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46952-6634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-664-8374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 S NORTON ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46952-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-573-6656
-----------------------------------------------------
Fax | 765-573-6658
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MD
-----------------------------------------------------
Name | WILLIAM A NETTEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 765-573-6656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------