Provider Demographics
NPI:1629296926
Name:LIN PAIN CLINIC LTD
Entity Type:Organization
Organization Name:LIN PAIN CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EI
Authorized Official - Middle Name:SHUN
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-0879
Mailing Address - Street 1:MARYVILLE PROFESSIONAL PARK
Mailing Address - Street 2:16B PROFESSIONAL PARK DRIVE
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-288-0879
Mailing Address - Fax:618-288-3351
Practice Address - Street 1:16B PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5672
Practice Address - Country:US
Practice Address - Phone:618-288-0879
Practice Address - Fax:618-288-3351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-055942174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055942Medicaid
ILD15986Medicare UPIN