1164451308 NPI number — MODERN PAIN CONSULTANTS

Table of content: (NPI 1164451308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164451308 NPI number — MODERN PAIN CONSULTANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN PAIN CONSULTANTS
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:
1164451308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 N ELM ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINSDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60521-3644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-482-4500
Provider Business Mailing Address Fax Number:
708-482-4502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 N ELM ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HINSDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60521-3644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-482-4500
Provider Business Practice Location Address Fax Number:
708-482-4502
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOEHN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-482-4500

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 132321800 . This is a "US DEPT LABOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 720000088 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01608719 . This is a "BLUE CROSS GRP ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 050054545 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 050054546 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 720000089 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com