Provider Demographics
NPI:1104932185
Name:INSTITUTE OF COMPREHENSIVE PAIN MANAGEMENT, LLC
Entity type:Organization
Organization Name:INSTITUTE OF COMPREHENSIVE PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUNIPACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-887-9999
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:DEPT 212
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-6069
Mailing Address - Country:US
Mailing Address - Phone:866-333-6656
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:30 SOUTH EMERSON AVENUE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-802-6317
Practice Address - Fax:317-870-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040468208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000493208OtherANTHEM
IN200833690Medicaid
IN000000493208OtherANTHEM
INF43437Medicare UPIN