1801185616 NPI number — ILLINOIS SPINE AND PAIN CENTER SC

Table of content: (NPI 1801185616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801185616 NPI number — ILLINOIS SPINE AND PAIN CENTER SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS SPINE AND PAIN CENTER 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:
1801185616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2466 MOMENTUM PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60689-5324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-347-2332
Provider Business Mailing Address Fax Number:
217-347-2313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901MEDICAL PARK DR.
Provider Second Line Business Practice Location Address:
SUITE #201
Provider Business Practice Location Address City Name:
EFFINGHAM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62401-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-347-2332
Provider Business Practice Location Address Fax Number:
217-347-2313
Provider Enumeration Date:
04/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
OGAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN / OWNER
Authorized Official Telephone Number:
217-347-2332

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com