Provider Demographics
NPI:1184690570
Name:PAIN CARE SURGERY, PC
Entity Type:Organization
Organization Name:PAIN CARE SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAXMAIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHIKANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-997-7820
Mailing Address - Street 1:108 AIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5841
Mailing Address - Country:US
Mailing Address - Phone:618-997-7820
Mailing Address - Fax:618-997-6721
Practice Address - Street 1:108 AIRWAY DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5841
Practice Address - Country:US
Practice Address - Phone:618-997-7820
Practice Address - Fax:618-997-6721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002900261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL100812OtherHEALTH ALLIANCE
ILBC#50386OtherBLUE CROSS/BLUE SHIELD
IL=========6295901Medicaid
IL=========6295901Medicaid