Healthcare Provider Details

I. General information

NPI: 1508355876
Provider Name (Legal Business Name): INTEGRATED PAIN MANAGEMENT, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4906 N. WESTERN
CHICAGO IL
60625-1922
US

IV. Provider business mailing address

244 E ROOSEVELT RD
LOMBARD IL
60148-4647
US

V. Phone/Fax

Practice location:
  • Phone: 773-334-3767
  • Fax: 312-635-0108
Mailing address:
  • Phone: 312-842-4588
  • Fax: 312-635-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036105506
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036105506
License Number StateIL

VIII. Authorized Official

Name: TIAN XIA
Title or Position: OWNER
Credential: D.O.
Phone: 312-842-4588