Provider Demographics
NPI:1730138637
Name:EVERGREEN ANESTHESIA & PAIN MANAGEMENT SERVICES, S.C.
Entity Type:Organization
Organization Name:EVERGREEN ANESTHESIA & PAIN MANAGEMENT SERVICES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-836-7015
Mailing Address - Street 1:185 PENNY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1454
Mailing Address - Country:US
Mailing Address - Phone:847-836-7015
Mailing Address - Fax:
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2746
Practice Address - Country:US
Practice Address - Phone:708-422-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Not Answered208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL713860Medicare ID - Type Unspecified
IL338950Medicare ID - Type Unspecified