Basic Information
| Provider Information | |||||||||
| NPI: | 1639484512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS PAIN SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 WASHINGTON AVE | ||||||||
| Address2: | 390 | ||||||||
| City: | NEWPORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410711986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592914800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1790 NATIONS DR | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600319164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733073009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2010 | ||||||||
| LastUpdateDate: | 08/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | PAVLOVIC | ||||||||
| AuthorizedOfficialFirstName: | BOJAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7733073009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 036.115520 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301089505 | 01 | IL | LICENSE NUMBER | OTHER |