Basic Information
| Provider Information | |||||||||
| NPI: | 1801185616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS SPINE AND PAIN CENTER SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2466 MOMENTUM PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173472332 | ||||||||
| FaxNumber: | 2173472313 | ||||||||
| Practice Location | |||||||||
| Address1: | 901MEDICAL PARK DR. | ||||||||
| Address2: | SUITE #201 | ||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624010000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173472332 | ||||||||
| FaxNumber: | 2173472313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | OGAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2173472332 | ||||||||
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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 | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.