Provider Demographics
NPI:1114266749
Name:MID-AMERICAN ANESTHESIA AND PAIN PC
Entity Type:Organization
Organization Name:MID-AMERICAN ANESTHESIA AND PAIN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONION
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:847-615-2200
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0689
Mailing Address - Country:US
Mailing Address - Phone:847-615-2200
Mailing Address - Fax:847-615-2858
Practice Address - Street 1:4500 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1626
Practice Address - Country:US
Practice Address - Phone:563-742-5000
Practice Address - Fax:847-615-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34558207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty