Basic Information
| Provider Information | |||||||||
| NPI: | 1629373774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM PAIN CENTER OF LAKE COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5198 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004446110 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Practice Location | |||||||||
| Address1: | 1880 W WINCHESTER RD | ||||||||
| Address2: | #101 | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600485341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472819543 | ||||||||
| FaxNumber: | 8472819615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2011 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | BENYAMIN | ||||||||
| AuthorizedOfficialFirstName: | RAMSIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3096624321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MILLENNIUM PAIN CENTER LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.