Healthcare Provider Details

I. General information

NPI: 1730326687
Provider Name (Legal Business Name): BROOKSIDE ADVANCED CLINIC FOR PAIN,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

IV. Provider business mailing address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-9750
  • Fax: 815-469-9752
Mailing address:
  • Phone: 815-469-9750
  • Fax: 815-469-9752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number209003563
License Number StateIL

VIII. Authorized Official

Name: MR. DANIEL W BORVAN
Title or Position: PRESIDENT
Credential:
Phone: 815-469-9750