Basic Information
| Provider Information | |||||||||
| NPI: | 1881812279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MORTON GROVE PAIN CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY PAIN CENTERS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 WAUKEGAN RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MORTON GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600532127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479336974 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9000 WAUKEGAN RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MORTON GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600532127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479336974 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | IVANKOVICH | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PAIN CENTER | ||||||||
| AuthorizedOfficialTelephone: | 3129423135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.