1134268857 NPI number — PAIN MANAGEMENT ASSOCIATES USA

Table of content: (NPI 1134268857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134268857 NPI number — PAIN MANAGEMENT ASSOCIATES USA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT ASSOCIATES USA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134268857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 E LINCOLN HWY
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451-1849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-462-8602
Provider Business Mailing Address Fax Number:
815-462-8471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 E LINCOLN HWY
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-462-8602
Provider Business Practice Location Address Fax Number:
815-462-8471
Provider Enumeration Date:
02/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BORVAN
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
815-462-8602

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207Q00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 367500000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)