Healthcare Provider Details

I. General information

NPI: 1902016561
Provider Name (Legal Business Name): GREAT LAKE PAIN PHYSICIANS LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 TOWER CT STE # 190
GURNEE IL
60031-3336
US

IV. Provider business mailing address

15 TOWER CT STE # 190
GURNEE IL
60031-3336
US

V. Phone/Fax

Practice location:
  • Phone: 847-970-0885
  • Fax:
Mailing address:
  • Phone: 847-970-0885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036-084312
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036-084312
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036-084312
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036-084312
License Number StateIL

VIII. Authorized Official

Name: DR. ELIZA DIACONESCU
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 18479700885