Basic Information
| Provider Information | |||||||||
| NPI: | 1568087583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYNERGY INTEGRATIVE HEADACHE CENTER LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 191 WAUKEGAN RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600932744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739487557 | ||||||||
| FaxNumber: | 7739487558 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 WAUKEGAN RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600932744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739487557 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | FEOKTISTOV | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7737290835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.