Healthcare Provider Details

I. General information

NPI: 1124532593
Provider Name (Legal Business Name): CHICAGO PAIN MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6307 S STEWART AVE STE 205
CHICAGO IL
60621-3116
US

IV. Provider business mailing address

1044 N FRANCISCO AVE STE 404
CHICAGO IL
60622-2743
US

V. Phone/Fax

Practice location:
  • Phone: 773-868-6824
  • Fax: 773-868-6828
Mailing address:
  • Phone: 773-868-6824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036.086023
License Number StateIL

VIII. Authorized Official

Name: JAMES R DIESFELD
Title or Position: PRESIDENT
Credential: MD
Phone: 773-868-6824