Provider Demographics
NPI:1689905416
Name:PRAIRIESHORE PAIN CENTER, P.C.
Entity Type:Organization
Organization Name:PRAIRIESHORE PAIN CENTER, P.C.
Other - Org Name:ILLINOIS PAIN CENTER, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:CANER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-883-0077
Mailing Address - Street 1:185 MILWAUKEE AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069-3010
Mailing Address - Country:US
Mailing Address - Phone:847-883-0077
Mailing Address - Fax:847-883-0078
Practice Address - Street 1:185 MILWAUKEE AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3010
Practice Address - Country:US
Practice Address - Phone:847-883-0077
Practice Address - Fax:847-883-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-18
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-097308207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty