Provider Demographics
NPI:1801185616
Name:ILLINOIS SPINE AND PAIN CENTER SC
Entity Type:Organization
Organization Name:ILLINOIS SPINE AND PAIN CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-347-2332
Mailing Address - Street 1:2466 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5324
Mailing Address - Country:US
Mailing Address - Phone:217-347-2332
Mailing Address - Fax:217-347-2313
Practice Address - Street 1:901MEDICAL PARK DR.
Practice Address - Street 2:SUITE #201
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-0000
Practice Address - Country:US
Practice Address - Phone:217-347-2332
Practice Address - Fax:217-347-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty