Provider Demographics
NPI:1255754362
Name:INTERVENTIONAL PAIN MANAGEMENT OF NORTHERN ILLINOIS
Entity type:Organization
Organization Name:INTERVENTIONAL PAIN MANAGEMENT OF NORTHERN ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-316-0221
Mailing Address - Street 1:4338 MORSAY DR
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4877
Mailing Address - Country:US
Mailing Address - Phone:815-397-8500
Mailing Address - Fax:815-397-8588
Practice Address - Street 1:4338 MORSAY DR
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4877
Practice Address - Country:US
Practice Address - Phone:815-397-8500
Practice Address - Fax:815-397-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty