=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922145804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST PHYSICAN PAIN CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3522 E 95TH STREET
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-933-0791
-----------------------------------------------------
Fax | 773-933-4903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 CASCADE CT W
-----------------------------------------------------
City | BURR RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-887-1483
-----------------------------------------------------
Fax | 630-887-1483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RANJIT S WAHI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-933-0791
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------