Provider Demographics
NPI:1912202409
Name:GUARDIAN HEADACHE & PAIN MANAGEMENT INSTITUTE LLC
Entity Type:Organization
Organization Name:GUARDIAN HEADACHE & PAIN MANAGEMENT INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAIMOORAZY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-664-1747
Mailing Address - Street 1:PO BOX 5488
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61601-5488
Mailing Address - Country:US
Mailing Address - Phone:800-444-6110
Mailing Address - Fax:847-615-2858
Practice Address - Street 1:2203 EASTLAND DR
Practice Address - Street 2:SUITE 7
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7918
Practice Address - Country:US
Practice Address - Phone:309-808-1700
Practice Address - Fax:847-615-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086706207LP2900X, 208VP0014X
367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty