Provider Demographics
NPI:1437458536
Name:PAIN INSTITUTE, LTD
Entity Type:Organization
Organization Name:PAIN INSTITUTE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LONGO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:931-905-1720
Mailing Address - Street 1:4972 BENCHMARK CENTRE
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2070
Mailing Address - Country:US
Mailing Address - Phone:931-905-1720
Mailing Address - Fax:931-905-1721
Practice Address - Street 1:4972 BENCHMARK CENTRE DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2070
Practice Address - Country:US
Practice Address - Phone:931-905-1720
Practice Address - Fax:931-905-1721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5602001Medicare PIN