Healthcare Provider Details

I. General information

NPI: 1962979278
Provider Name (Legal Business Name): MIDWEST PAIN AND SPINE PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4354 W 63RD ST
CHICAGO IL
60629-5039
US

IV. Provider business mailing address

4354 W 63RD ST
CHICAGO IL
60629-5039
US

V. Phone/Fax

Practice location:
  • Phone: 773-482-5800
  • Fax: 773-362-2917
Mailing address:
  • Phone: 773-482-5800
  • Fax: 773-362-2768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DARREL J. SALDANHA
Title or Position: CEO
Credential:
Phone: 773-482-5800