Healthcare Provider Details

I. General information

NPI: 1922417427
Provider Name (Legal Business Name): PAIN & SPINE SUGICAL SUITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 ESSINGTON RD
JOLIET IL
60435-4912
US

IV. Provider business mailing address

744 ESSINGTON RD
JOLIET IL
60435-4912
US

V. Phone/Fax

Practice location:
  • Phone: 815-834-7200
  • Fax: 815-834-1307
Mailing address:
  • Phone: 815-834-7200
  • Fax: 815-834-1307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number36113508
License Number StateIL

VIII. Authorized Official

Name: MOLLY TOBIN
Title or Position: A/R REP
Credential:
Phone: 815-834-7200