Provider Demographics
NPI:1609224492
Name:PAIN MANAGEMENT SPECIALISTS LTD
Entity Type:Organization
Organization Name:PAIN MANAGEMENT SPECIALISTS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-231-4363
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0631
Mailing Address - Country:US
Mailing Address - Phone:224-231-4363
Mailing Address - Fax:866-642-1525
Practice Address - Street 1:5215 N CALIFORNIA AVE STE 880
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:773-293-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105360207L00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty