MEDICARE: INTEGRATED PAIN MANAGEMENT SC

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	332900000X	Non-Pharmacy Dispensing Site
2	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1326380072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED PAIN MANAGEMENT SC

Provider Business Mailing Address
First Line	:	244 E ROOSEVELT RD
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-4647
Country	:	US
Telephone Number	:	312-842-4588
Fax Number	:	630-495-7255

Provider Business Practice Location Address
First Line	:	3405 S HALSTED ST
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	:	CEO
Name	:	TIAN XIA
Credential	:	D.O
Telephone Number	:	312-842-4588

Provider Enumeration Date	:	03/20/2013
Last Update Date	:	05/16/2024

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