Healthcare Provider Details

I. General information

NPI: 1609424084
Provider Name (Legal Business Name): ILLINOIS PAIN AND THERAPY ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S WENTWORTH AVE
CHICAGO IL
60609-6300
US

IV. Provider business mailing address

5401 S WENTWORTH AVE
CHICAGO IL
60609-6300
US

V. Phone/Fax

Practice location:
  • Phone: 312-624-8364
  • Fax: 312-929-3323
Mailing address:
  • Phone: 312-624-8364
  • Fax: 312-929-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: NEEMA BAYRAN
Title or Position: CEO
Credential: MD
Phone: 312-624-8364