MEDICARE: RX PAIN MANAGEMENT GROUP PC

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	207R00000X	Internal Medicine Physician	036088691	IL
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	036088691	IL
3	208VP0000X	Pain Medicine Physician	036088691	IL
4	208000000X	Pediatrics Physician
5	207L00000X	Anesthesiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1620404	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1154334779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RX PAIN MANAGEMENT GROUP PC

Provider Business Mailing Address
First Line	:	3405 S HALSTED STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-6707
Country	:	US
Telephone Number	:	773-247-2131
Fax Number	:	773-247-3110

Provider Business Practice Location Address
First Line	:	3405 S HALSTED STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-6707
Country	:	US
Telephone Number	:	773-247-2131
Fax Number	:	773-247-3110

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. YAN DENG
Credential	:
Telephone Number	:	773-247-2131

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	03/11/2016

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