Healthcare Provider Details

I. General information

NPI: 1649696147
Provider Name (Legal Business Name): PREMIERCARE ANESTHESIA & PAIN P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2014
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 W FULLERTON AVE
CHICAGO IL
60647-2497
US

IV. Provider business mailing address

200 W MENOMONEE ST UNIT 4
CHICAGO IL
60614-5313
US

V. Phone/Fax

Practice location:
  • Phone: 312-475-1203
  • Fax: 312-929-3739
Mailing address:
  • Phone: 630-400-4881
  • Fax: 312-929-3739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036.087570
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.087570
License Number StateIL

VIII. Authorized Official

Name: DR. DANIEL MAKSIMOVICH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 630-400-4881