Healthcare Provider Details

I. General information

NPI: 1053588079
Provider Name (Legal Business Name): THE PAIN CENTER OF ILLINOIS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 W DIVISION ST
CHICAGO IL
60622-8521
US

IV. Provider business mailing address

2041 W DIVISION ST
CHICAGO IL
60622-8521
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036-103729
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: NEEMA BAYRAN
Title or Position: C.E.O.
Credential: MD
Phone: 312-593-1580