Provider Demographics
NPI:1114037066
Name:FOX VALLEY PAIN CENTER SERVICE CORPORATION
Entity Type:Organization
Organization Name:FOX VALLEY PAIN CENTER SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNDARARAJ
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHERALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-888-4432
Mailing Address - Street 1:507 WEXFORD CT
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-5655
Mailing Address - Country:US
Mailing Address - Phone:630-584-8381
Mailing Address - Fax:630-524-9018
Practice Address - Street 1:1710 N RANDALL RD
Practice Address - Street 2:370
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9400
Practice Address - Country:US
Practice Address - Phone:847-888-4432
Practice Address - Fax:847-888-4436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077595208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216172Medicare PIN
IL213307Medicare PIN