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NPI Code Detail

MEDICARE: MEDICOS PAIN & SURGICAL SPECIALISTS, S.C.

MEDICARE: MEDICOS PAIN & SURGICAL SPECIALISTS, S.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208VP0000XPain Medicine Physician

General Provider Information

NPI Number : 1003063108
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEDICOS PAIN & SURGICAL SPECIALISTS, S.C.
Provider Business Mailing Address
First Line : 4176 W MONTROSE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60641-2161
Country : US
Telephone Number : 773-283-3131
Fax Number : 773-283-3610
Provider Business Practice Location Address
First Line : 712 N DEARBORN ST
Second Line :
City : CHICAGO
State : IL
Zip : 60654-3818
Country : US
Telephone Number : 773-283-3131
Fax Number : 773-283-3610
Authorized Official
Title or Position : MANAGER
Name : DR. DERRICK D. WALLERY
Credential : D.C.
Telephone Number : 773-283-3131
Provider Enumeration Date : 08/20/2008
Last Update Date : 08/20/2008

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