Healthcare Provider Details

I. General information

NPI: 1174992119
Provider Name (Legal Business Name): MIDWEST PAIN SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3139 W 111TH ST
CHICAGO IL
60655-2205
US

IV. Provider business mailing address

3139 W 111TH ST
CHICAGO IL
60655-2205
US

V. Phone/Fax

Practice location:
  • Phone: 312-208-4492
  • Fax: 773-337-9106
Mailing address:
  • Phone: 312-208-4492
  • Fax: 773-337-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036082067
License Number StateIL

VIII. Authorized Official

Name: LYNNETTE MCROY
Title or Position: BILLING COORDINATOR
Credential:
Phone: 773-767-3822