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General NPI Number Information
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NPI Number | 1902016561
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Entity Type | Organization
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Legal Business Name | GREAT LAKE PAIN PHYSICIANS LTD.
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 11/25/2014
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Provider Practice Location Address
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Address Line | 15 TOWER CT STE # 190
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City | GURNEE
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State | IL
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Zip | 60031-3336
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Country | US
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Telephone | 847-970-0885
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Fax |
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Provider Business Mailing Address
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Address Line | 15 TOWER CT STE # 190
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City | GURNEE
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State | IL
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Zip | 60031-3336
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Country | US
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Telephone | 847-970-0885
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. ELIZA DIACONESCU
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Credential | M.D.
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Telephone | 18479700885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 036-084312
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 036-084312
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 036-084312
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 036-084312
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License Number State | IL
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