Provider Demographics
NPI:1437476702
Name:COMPREHENSIVE PAIN & REHABILITATION CENTER P C
Entity type:Organization
Organization Name:COMPREHENSIVE PAIN & REHABILITATION CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-816-0141
Mailing Address - Street 1:7300 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1641
Mailing Address - Country:US
Mailing Address - Phone:847-763-8010
Mailing Address - Fax:847-763-8012
Practice Address - Street 1:7300 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1641
Practice Address - Country:US
Practice Address - Phone:847-763-8010
Practice Address - Fax:847-763-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008098111N00000X
IL038011280111N00000X
IL336.057488208100000X
IL036.0562122081N0008X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
366760OtherMEDICARE PTAN
366760OtherMEDICARE PTAN