Provider Demographics
NPI:1639484512
Name:ILLINOIS PAIN SPECIALISTS, LLC
Entity Type:Organization
Organization Name:ILLINOIS PAIN SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVLOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-307-3009
Mailing Address - Street 1:601 WASHINGTON AVE
Mailing Address - Street 2:390
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-1986
Mailing Address - Country:US
Mailing Address - Phone:859-291-4800
Mailing Address - Fax:
Practice Address - Street 1:1790 NATIONS DR
Practice Address - Street 2:SUITE 111
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-9164
Practice Address - Country:US
Practice Address - Phone:773-307-3009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.115520208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4301089505OtherLICENSE NUMBER