=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962401745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST PAIN MANAGEMENT CENTERS,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2005
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8840 CALUMET AVE SUITE 103
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-836-7246
-----------------------------------------------------
Fax | 219-836-6454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8840 CALUMET AVE SUITE 103
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-836-7246
-----------------------------------------------------
Fax | 219-836-6454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | SHANU KONDAMURI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 219-836-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------