Provider Demographics
NPI:1487872867
Name:PALOS PAIN CENTER
Entity type:Organization
Organization Name:PALOS 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 1:7600 W COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1001
Mailing Address - Country:US
Mailing Address - Phone:708-923-9771
Mailing Address - Fax:
Practice Address - Street 1:7600 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1001
Practice Address - Country:US
Practice Address - Phone:708-923-9771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615142OtherBCBS GROUP NUMBER
IL646410Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER