Provider Demographics
NPI:1124376736
Name:ILLINOIS SPINE INSTITUTE,S.C.
Entity Type:Organization
Organization Name:ILLINOIS SPINE INSTITUTE,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:8473-303-1200
Mailing Address - Street 1:360 STATION DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7978
Mailing Address - Country:US
Mailing Address - Phone:847-303-1200
Mailing Address - Fax:847-303-1210
Practice Address - Street 1:360 STATION DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7978
Practice Address - Country:US
Practice Address - Phone:847-303-1200
Practice Address - Fax:847-303-1210
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS SPINE INSTITUTE,S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042620019174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211155Medicare UPIN