1093146862 NPI number — COMPREHENSIVE PAIN CARE CENTER INC

Table of content: (NPI 1093146862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093146862 NPI number — COMPREHENSIVE PAIN CARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE PAIN CARE CENTER INC
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:
6
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:
1093146862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8S180 S VINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-5542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-479-6522
Provider Business Mailing Address Fax Number:
708-286-6461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5669 W 95TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60453-2382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-634-2627
Provider Business Practice Location Address Fax Number:
630-246-3166
Provider Enumeration Date:
12/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ALKHUDARI
Authorized Official First Name:
AZZAM
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-634-2627

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  036113149 , 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: 036113149 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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