Provider Demographics
NPI:1679878698
Name:ADVANCED INTERVENTIONAL SPINE AND PAIN INSTITUTE. LLC
Entity Type:Organization
Organization Name:ADVANCED INTERVENTIONAL SPINE AND PAIN INSTITUTE. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HONGKAI
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:DU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-767-3814
Mailing Address - Street 1:PO BOX 24001
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-9001
Mailing Address - Country:US
Mailing Address - Phone:618-767-3814
Mailing Address - Fax:618-257-6671
Practice Address - Street 1:4700 MEMORIAL DRIVE, SUITE 230 PAIN CENTER
Practice Address - Street 2:4700 MEMORIAL DRIVE, MEMORIAL HOSPITAL
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-257-5902
Practice Address - Fax:618-257-6671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-22
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111184208100000X, 208VP0014X, 261QP3300X
IL361111842081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H93504Medicare UPIN