Provider Demographics
NPI:1881812279
Name:MORTON GROVE PAIN CENTER
Entity type:Organization
Organization Name:MORTON GROVE PAIN CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PAIN CENTER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:IVANKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-942-3135
Mailing Address - Street 1:9000 WAUKEGAN RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2127
Mailing Address - Country:US
Mailing Address - Phone:847-933-6974
Mailing Address - Fax:
Practice Address - Street 1:9000 WAUKEGAN RD
Practice Address - Street 2:SUITE 220
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2127
Practice Address - Country:US
Practice Address - Phone:847-933-6974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty