MEDICARE: SPINE CIN OF INDIANAPOLIS LLC

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	207XS0117X	Orthopaedic Surgery of the Spine Physician		IN
2	207X00000X	Orthopaedic Surgery Physician		IN

General Provider Information

NPI Number	:	1548768815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE CIN OF INDIANAPOLIS LLC

Provider Business Mailing Address
First Line	:	102 WOODMONT BLVD STE 350
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37205-2216
Country	:	US
Telephone Number	:	615-386-0064
Fax Number	:	615-386-0067

Provider Business Practice Location Address
First Line	:	120 E MARKET ST STE 1265
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-3250
Country	:	US
Telephone Number	:	615-386-0064
Fax Number	:	615-386-0067

Authorized Official
Title or Position	:	SVP, MARKETING AND COMMUNICATIONS
Name	:	JOHN HANNON
Credential	:
Telephone Number	:	615-386-0064

Provider Enumeration Date	:	01/31/2018
Last Update Date	:	01/12/2022

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