Healthcare Provider Details

I. General information

NPI: 1023062460
Provider Name (Legal Business Name): IBARRA INTERVENTIONAL PAIN MANAGEMENT SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W STEPHENSON ST
FREEPORT IL
61032-4864
US

IV. Provider business mailing address

PO BOX 123
FREEPORT IL
61032-0123
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6159
  • Fax:
Mailing address:
  • Phone: 815-235-2353
  • Fax: 815-235-2353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number036082621
License Number StateIL

VIII. Authorized Official

Name: JUAN M. IBARRA
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 815-235-2353