Basic Information
| Provider Information | |||||||||
| NPI: | 1912202409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUARDIAN HEADACHE & PAIN MANAGEMENT INSTITUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5488 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616015488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004446110 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Practice Location | |||||||||
| Address1: | 2203 EASTLAND DR | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617047918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098081700 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2011 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | TAIMOORAZY | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3096641747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 036086706 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 208VP0014X | 036086706 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.