Provider Demographics
NPI:1265824734
Name:ELGIN MEDICAL PAIN MANAGEMENT
Entity Type:Organization
Organization Name:ELGIN MEDICAL PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HARTLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-404-3064
Mailing Address - Street 1:1116 PALMER CT
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6938
Mailing Address - Country:US
Mailing Address - Phone:815-404-3064
Mailing Address - Fax:847-697-3475
Practice Address - Street 1:1037 E WOODFIELD RD.
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173
Practice Address - Country:US
Practice Address - Phone:815-404-3064
Practice Address - Fax:847-697-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 207LP2900X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1500023738OtherCITY OF ELGIN LICENSE