Basic Information
| Provider Information | |||||||||
| NPI: | 1508457383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN CENTERS OF CHICAGO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 WALT WHITMAN RD STE 300 | ||||||||
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| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5666 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611082425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157290450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2021 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | BERNOCCO | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT TEAM LEAD | ||||||||
| AuthorizedOfficialTelephone: | 5169453163 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.