Provider Demographics
NPI:1275690521
Name:BRIDGEPORT PAIN CONTROL
Entity Type:Organization
Organization Name:BRIDGEPORT PAIN CONTROL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-254-8977
Mailing Address - Street 1:735 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4481
Mailing Address - Country:US
Mailing Address - Phone:773-254-8977
Mailing Address - Fax:773-254-8944
Practice Address - Street 1:735 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4481
Practice Address - Country:US
Practice Address - Phone:773-254-8977
Practice Address - Fax:773-254-8944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616680OtherBLUE CROSS
IL1616680OtherBLUE CROSS