MEDICARE: PAIN MANAGEMENT CENTER OF SOUTHERN INDIANA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician		IN
2	208VP0000X	Pain Medicine Physician		IN

General Provider Information

NPI Number	:	1417284415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MANAGEMENT CENTER OF SOUTHERN INDIANA

Provider Business Mailing Address
First Line	:	4330 S ROCKPORT RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-9765
Country	:	US
Telephone Number	:	812-333-7246
Fax Number	:	812-333-4471

Provider Business Practice Location Address
First Line	:	12 W MAIN ST
Second Line	:
City	:	BLOOMFIELD
State	:	IN
Zip	:	47424-1424
Country	:	US
Telephone Number	:	812-824-5690
Fax Number	:	812-824-5692

Authorized Official
Title or Position	:	OWNER
Name	:	KAMAL K. TIWARI
Credential	:	MD
Telephone Number	:	812-333-7246

Provider Enumeration Date	:	11/11/2009
Last Update Date	:	11/11/2009

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Directions to “PAIN MANAGEMENT CENTER OF SOUTHERN INDIANA ” Practice Location

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