1801185616 NPI number — ILLINOIS SPINE AND PAIN CENTER 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 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:
05/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 736909
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:
60673-1424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-974-9366
Provider Business Mailing Address Fax Number:
800-801-3765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 INTERSTATE DR
Provider Second Line Business Practice Location Address:
OLYMPIAN SURGICAL SUITES
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-974-9366
Provider Business Practice Location Address Fax Number:
800-801-3765
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)





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