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General NPI Number Information
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NPI Number | 1912074659
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Entity Type | Organization
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Legal Business Name | MICHIANA SPINE, SPORTS & OCCUPATIONAL REHAB, PC
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 11/03/2022
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Provider Practice Location Address
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Address Line | 3740 EDISON LAKES PKWY
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City | MISHAWAKA
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State | IN
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Zip | 46545-3474
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Country | US
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Telephone | 574-252-4150
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Fax | 574-252-4159
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Provider Business Mailing Address
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Address Line | 3740 EDISON LAKES PKWY
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City | MISHAWAKA
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State | IN
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Zip | 46545-3474
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Country | US
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Telephone | 574-252-4150
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Fax | 574-252-4159
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEVIN GENE DREW
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Credential | M.D.
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Telephone | 574-252-4150
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 01042863
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License Number State | IN
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