Healthcare Provider Details

I. General information

NPI: 1437519410
Provider Name (Legal Business Name): HEGEWISCH SPINE PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6626 W CERMAK RD
BERWYN IL
60402
US

IV. Provider business mailing address

7653 W MONTROSE AVE
NORRIDGE IL
60706
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-7246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number036108759
License Number StateIL

VIII. Authorized Official

Name: NATALYA SMIRNOVA
Title or Position: OFFICE MANAGER
Credential:
Phone: 708-788-7246