MEDICARE: INDIANA INTERVENTIONAL PAIN, 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	208VP0000X	Pain Medicine Physician		IN
2	207LP2900X	Pain Medicine (Anesthesiology) Physician		IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DE7729	OTHER	IN	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
3	000000373172	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1982648762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA INTERVENTIONAL PAIN, LLC

Provider Business Mailing Address
First Line	:	PO BOX 3056
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46206-3056
Country	:	US
Telephone Number	:	317-567-2180
Fax Number	:	317-567-2191

Provider Business Practice Location Address
First Line	:	5445 E 16TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46218-4869
Country	:	US
Telephone Number	:	317-355-4358
Fax Number	:	317-567-2191

Authorized Official
Title or Position	:	PRESIDENT-OWNER
Name	:	JOHN B SWOFFORD
Credential	:	D.O.
Telephone Number	:	317-567-2180

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	11/25/2009

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Directions to “INDIANA INTERVENTIONAL PAIN, LLC ” Practice Location

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