1710999461 NPI number — INTERVENTIONAL PAIN CONSULTANTS, SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710999461 NPI number — INTERVENTIONAL PAIN CONSULTANTS, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN CONSULTANTS, SC
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:
1710999461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
744 W MICHIGAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49201-1909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-787-6440
Provider Business Mailing Address Fax Number:
517-787-4146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 MIDWEST RD
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
OAK BROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60523-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-228-2615
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLK
Authorized Official First Name:
JENIFER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AUTHORIZED REPRESENTATIVE
Authorized Official Telephone Number:
708-228-2615

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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