1639484512 NPI number — ILLINOIS PAIN SPECIALISTS, LLC

Table of content: CONSTANTINE ARCHIMANDRITIS (NPI 1053332288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639484512 NPI number — ILLINOIS PAIN SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS PAIN SPECIALISTS, LLC
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:
1639484512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 WASHINGTON AVE
Provider Second Line Business Mailing Address:
390
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41071-1986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-291-4800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1790 NATIONS DR
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
GURNEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60031-9164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-307-3009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PAVLOVIC
Authorized Official First Name:
BOJAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-307-3009

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  036.115520 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4301089505 . This is a "LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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