Healthcare Provider Details

I. General information

NPI: 1225196488
Provider Name (Legal Business Name): MILLENNIUM PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

11350 MCCORMICK RD EXECUTIVE PLAZA 1, SUITE 501
HUNT VALLEY MD
21031-1002
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-4321
  • Fax:
Mailing address:
  • Phone: 410-329-1071
  • Fax: 410-329-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAMSIN BENYAMIN
Title or Position: PRESIDENT
Credential: MD
Phone: 309-662-4321