Provider Demographics
NPI:1912157108
Name:SUBURBAN PAIN CARE SURGICAL FACILITY LLC
Entity Type:Organization
Organization Name:SUBURBAN PAIN CARE SURGICAL FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELTON
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-810-0451
Mailing Address - Street 1:73 W 61ST ST
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2615
Mailing Address - Country:US
Mailing Address - Phone:630-810-0451
Mailing Address - Fax:877-446-3870
Practice Address - Street 1:18425 W CREEK DR
Practice Address - Street 2:STE B
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6767
Practice Address - Country:US
Practice Address - Phone:630-810-0451
Practice Address - Fax:877-446-3870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty