Healthcare Provider Details

I. General information

NPI: 1417363813
Provider Name (Legal Business Name): ADVANCE PAIN & ANESTHESIA CONSULTANTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10215 W. ROOSEVELT RD. SUITE 100
WESTCHESTER IL
60154-7526
US

IV. Provider business mailing address

425 JOLIET STREET SUITE 400
DYER IN
46311-1768
US

V. Phone/Fax

Practice location:
  • Phone: 708-483-7007
  • Fax: 708-562-0129
Mailing address:
  • Phone: 219-488-0165
  • Fax: 219-865-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDOLPH YOON CHANG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 219-488-0165