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General NPI Number Information
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NPI Number | 1023062460
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Entity Type | Organization
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Legal Business Name | IBARRA INTERVENTIONAL PAIN MANAGEMENT SC
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Dates
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Enumeration Date | 05/20/2006
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Last Update Date | 03/29/2010
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Provider Practice Location Address
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Address Line | 1045 W STEPHENSON ST
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City | FREEPORT
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State | IL
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Zip | 61032-4864
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Country | US
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Telephone | 815-599-6159
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 123
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City | FREEPORT
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State | IL
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Zip | 61032-0123
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Country | US
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Telephone | 815-235-2353
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Fax | 815-235-2353
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | JUAN M. IBARRA
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Credential | M.D.
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Telephone | 815-235-2353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number | 036082621
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License Number State | IL
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