Basic Information
| Provider Information | |||||||||
| NPI: | 1568078087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL PAIN CONSULTANTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2023 VADALABENE DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182886722 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2023 VADALABENE DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1852886722 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | PRUETZEL | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | ROHLAND | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6182058302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
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.