Provider Demographics
NPI:1548696446
Name:MIDWEST PAIN CLINIC INTERVENTIONAL LLC
Entity type:Organization
Organization Name:MIDWEST PAIN CLINIC INTERVENTIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-872-9158
Mailing Address - Street 1:350 COMMERCE SQ
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3376
Mailing Address - Country:US
Mailing Address - Phone:219-872-9158
Mailing Address - Fax:219-873-9196
Practice Address - Street 1:350 COMMERCE SQ
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3376
Practice Address - Country:US
Practice Address - Phone:219-872-9158
Practice Address - Fax:219-873-9196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031628A261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1719Medicare PIN
ILF100107816Medicare PIN