Healthcare Provider Details

I. General information

NPI: 1447290713
Provider Name (Legal Business Name): INTEGRATED PAIN MANAGEMENT SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 E ROOSEVELT RD
LOMBARD IL
60148-4647
US

IV. Provider business mailing address

244 E ROOSEVELT RD
LOMBARD IL
60148-4647
US

V. Phone/Fax

Practice location:
  • Phone: 312-842-4588
  • Fax: 312-635-0108
Mailing address:
  • Phone: 312-842-4588
  • Fax: 630-599-7149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036-105506
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: TIAN XIA
Title or Position: OWNER
Credential: DO
Phone: 312-842-4588