Provider Demographics
NPI:1790274041
Name:INTEGRATED PAIN MANAGEMENT, SC
Entity Type:Organization
Organization Name:INTEGRATED PAIN MANAGEMENT, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:XIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:312-842-4588
Mailing Address - Street 1:244 E ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4647
Mailing Address - Country:US
Mailing Address - Phone:312-842-4588
Mailing Address - Fax:312-635-0108
Practice Address - Street 1:2674 N. HALSTED
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2302
Practice Address - Country:US
Practice Address - Phone:773-661-1170
Practice Address - Fax:312-635-0108
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED PAIN MANAGEMENT, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105506207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105506Medicaid
IL210115OtherMEDICARE PTAN