Healthcare Provider Details

I. General information

NPI: 1255662417
Provider Name (Legal Business Name): CHICAGO PAIN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6224 S PULASKI RD
CHICAGO IL
60629-4610
US

IV. Provider business mailing address

6224 S PULASKI RD
CHICAGO IL
60629-4610
US

V. Phone/Fax

Practice location:
  • Phone: 773-735-8200
  • Fax:
Mailing address:
  • Phone: 773-735-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number028007050
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009053
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036113839
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036111230
License Number StateIL

VIII. Authorized Official

Name: DR. MARK COHEN
Title or Position: PRESIDENT
Credential: D.C.
Phone: 773-735-8200