Basic Information
| Provider Information | |||||||||
| NPI: | 1700833811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAX | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 387 SHUMAN BLVD | ||||||||
| Address2: | SUITE 240W | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605638450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303550450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605407430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303550450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036107193 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 036107193 | IL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036107193 | 05 | IL | MEDICAID |