Healthcare Provider Details

I. General information

NPI: 1417370537
Provider Name (Legal Business Name): INTERVENTIONS IN PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 BLACKHAWK RD
ROCK ISLAND IL
61201-7039
US

IV. Provider business mailing address

PO BOX 689
LAKE FOREST IL
60045-0689
US

V. Phone/Fax

Practice location:
  • Phone: 309-428-7055
  • Fax:
Mailing address:
  • Phone: 847-615-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036090677
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KERRY PANOZZO
Title or Position: OWNER
Credential: MD
Phone: 309-428-7055