Basic Information
| Provider Information | |||||||||
| NPI: | 1114037066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOX VALLEY PAIN CENTER SERVICE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 507 WEXFORD CT | ||||||||
| Address2: | |||||||||
| City: | ST CHARLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601755655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305848381 | ||||||||
| FaxNumber: | 6305249018 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 N RANDALL RD | ||||||||
| Address2: | 370 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601239400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478884432 | ||||||||
| FaxNumber: | 8478884436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | CHERALA | ||||||||
| AuthorizedOfficialFirstName: | SUNDARARAJ | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8478884432 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 036077595 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.