Basic Information
| Provider Information | |||||||||
| NPI: | 1225522063 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL PAIN CONSULTANTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 PROFESSIONAL DR STE B | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184657177 | ||||||||
| FaxNumber: | 6184657176 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 PROFESSIONAL DR STE B | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184657177 | ||||||||
| FaxNumber: | 6184657176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2018 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUENGER | ||||||||
| AuthorizedOfficialFirstName: | WYNNDEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6184657177 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.