MEDICARE: THE PAIN CENTER OF ILLINOIS INC.

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
1	174400000X	Specialist	036-103729	IL
2	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1053588079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PAIN CENTER OF ILLINOIS INC.

Provider Business Mailing Address
First Line	:	2041 W DIVISION ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-8521
Country	:	US
Telephone Number	:	312-624-8364
Fax Number	:

Provider Business Practice Location Address
First Line	:	2041 W DIVISION ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-8521
Country	:	US
Telephone Number	:	312-624-8364
Fax Number	:	312-929-3323

Authorized Official
Title or Position	:	C.E.O.
Name	:	NEEMA BAYRAN
Credential	:	MD
Telephone Number	:	312-593-1580

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	09/24/2024

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