Provider Demographics
NPI:1902016561
Name:GREAT LAKE PAIN PHYSICIANS LTD.
Entity Type:Organization
Organization Name:GREAT LAKE PAIN PHYSICIANS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIACONESCU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:1847-970-0885
Mailing Address - Street 1:15 TOWER CT
Mailing Address - Street 2:STE # 190
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3336
Mailing Address - Country:US
Mailing Address - Phone:847-970-0885
Mailing Address - Fax:
Practice Address - Street 1:15 TOWER CT
Practice Address - Street 2:STE # 190
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3336
Practice Address - Country:US
Practice Address - Phone:847-970-0885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084312207LP2900X, 2081P2900X, 208D00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty