Healthcare Provider Details

I. General information

NPI: 1316580541
Provider Name (Legal Business Name): SPECIALTY PAIN ANESTHESIA REHABILITATION CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 E GRAND AVE
FOX LAKE IL
60020-1684
US

IV. Provider business mailing address

6615 GRAND AVE # 1037
GURNEE IL
60031-4591
US

V. Phone/Fax

Practice location:
  • Phone: 847-370-6712
  • Fax:
Mailing address:
  • Phone: 847-363-0863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN LEUTHNER
Title or Position: OWNER
Credential:
Phone: 847-363-0863