Healthcare Provider Details

I. General information

NPI: 1073865291
Provider Name (Legal Business Name): GREAT RIVER PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 AVENUE OF THE CITIES
MOLINE IL
61265-4860
US

IV. Provider business mailing address

1634 AVENUE OF THE CITIES
MOLINE IL
61265-4860
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-9711
  • Fax: 309-762-9747
Mailing address:
  • Phone: 309-762-9711
  • Fax: 309-762-9747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036118384
License Number StateIL

VIII. Authorized Official

Name: DR. SANJAY SUNDAR
Title or Position: OWNER
Credential: MD
Phone: 312-613-9999