Provider Demographics
NPI:1053840124
Name:GUARDIAN INTERVENTIONAL PAIN MANAGEMENT INSTITUTE LLC
Entity Type:Organization
Organization Name:GUARDIAN INTERVENTIONAL PAIN MANAGEMENT INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:EL-ANSARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-274-9720
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2203 EASTLAND DR STE 7
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7924
Practice Address - Country:US
Practice Address - Phone:309-808-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty