Provider Demographics
NPI:1962401745
Name:MIDWEST PAIN MANAGEMENT CENTERS,LLC
Entity type:Organization
Organization Name:MIDWEST PAIN MANAGEMENT CENTERS,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANU
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAMURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-7246
Mailing Address - Street 1:8840 CALUMET AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2529
Mailing Address - Country:US
Mailing Address - Phone:219-836-7246
Mailing Address - Fax:219-836-6454
Practice Address - Street 1:8840 CALUMET AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2529
Practice Address - Country:US
Practice Address - Phone:219-836-7246
Practice Address - Fax:219-836-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200095110AMedicaid
GACE8846OtherRAILROAD MEDICARE
IL90001076OtherBCBS OF ILLINOIS
IN=========OtherEIN
GACE8846OtherRAILROAD MEDICARE
IN409950Medicare ID - Type Unspecified