1033155080 NPI number — INTERVENTIONAL PAIN MANAGEMENT, LTD.

Table of content: (NPI 1033155080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033155080 NPI number — INTERVENTIONAL PAIN MANAGEMENT, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN MANAGEMENT, LTD.
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:
1033155080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/28/2013
NPI Reactivation Date:
10/14/2015

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18221 TORRENCE AVE
Provider Second Line Business Mailing Address:
SUITE 1C
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60438-2870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-895-9450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10220 WICKER AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SAINT JOHN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46373-9424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-515-6943
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLLACHEK
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
708-474-7650

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  60548471 , 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)





Copyright © 2007-2025 www.npivalidator.com