MEDICARE: ADVANCED SPINE & PAIN MANAGEMENT INC

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	332B00000X	Durable Medical Equipment & Medical Supplies		OH
2	363LA2200X	Adult Health Nurse Practitioner
3	208VP0000X	Pain Medicine Physician	34.008823	OH
4	208VP0014X	Interventional Pain Medicine Physician	34.008823	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
15	P00415701	OTHER	OH	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	296827989001	OTHER		MEDICAL MUTUAL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	617433400	OTHER	OH	DEPT OF LABOR - MD
5	617465100	OTHER	OH	DEPT. OF LABOR - APRN
6	150730	OTHER	OH	NATIONWIDE
7	6226080	OTHER	OH	CIGNA
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	317306	OTHER	OH	AMERIGROUP
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	000000488997	OTHER	OH	ANTHEM
12	617433404	OTHER	OH	US DEPT OF LABOR - EATON OFFICE
13	617433403	OTHER	OH	US DEPT OF LABOR - SPRINGFIELD OFFICE
14	617433406	OTHER	OH	US DEPT OF LABOR - SPRINGBORO OFFICE

General Provider Information

NPI Number	:	1790881746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED SPINE & PAIN MANAGEMENT INC

Provider Business Mailing Address
First Line	:	7691 5 MILE RD
Second Line	:	SUITE 10
City	:	CINCINNATI
State	:	OH
Zip	:	45230-2163
Country	:	US
Telephone Number	:	513-624-7246
Fax Number	:	513-624-6900

Provider Business Practice Location Address
First Line	:	7691 5 MILE RD
Second Line	:	SUITE 10
City	:	CINCINNATI
State	:	OH
Zip	:	45230-4348
Country	:	US
Telephone Number	:	513-624-7246
Fax Number	:	513-624-6900

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MUKARRAM ALI KHAN
Credential	:	D.O.
Telephone Number	:	513-624-7246

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	06/28/2016

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Directions to “ADVANCED SPINE & PAIN MANAGEMENT INC ” Practice Location

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