Provider Demographics
NPI:1952337453
Name:ILLINOIS REGIONAL PAIN INSTITUTE, S.C.
Entity Type:Organization
Organization Name:ILLINOIS REGIONAL PAIN INSTITUTE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCCIANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-692-7246
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE #416
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-7246
Mailing Address - Fax:309-692-7226
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE #416
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-7246
Practice Address - Fax:309-692-7226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114669174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213765Medicare PIN
ILH91167Medicare UPIN