Provider Demographics
NPI:1417370537
Name:INTERVENTIONS IN PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:INTERVENTIONS IN PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PANOZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-428-7055
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:
Practice Address - Street 1:4110 BLACKHAWK RD
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7039
Practice Address - Country:US
Practice Address - Phone:309-428-7055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090677207LP2900X
261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty