Healthcare Provider Details

I. General information

NPI: 1740692532
Provider Name (Legal Business Name): IMMEDIATE PAIN CARE OF FLOSSMOOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3486 VOLLMER RD
OLYMPIA FIELDS IL
60461-1018
US

IV. Provider business mailing address

7991 SOLUTIONS CTR
CHICAGO IL
60677-7006
US

V. Phone/Fax

Practice location:
  • Phone: 630-560-4299
  • Fax: 630-701-1007
Mailing address:
  • Phone: 630-560-4299
  • Fax: 630-701-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STUART BERNSEN
Title or Position: CEO
Credential:
Phone: 630-560-6506