Provider Demographics
NPI:1073865291
Name:GREAT RIVER PAIN CENTER LLC
Entity type:Organization
Organization Name:GREAT RIVER PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-613-9999
Mailing Address - Street 1:1634 AVENUE OF THE CITIES
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-4860
Mailing Address - Country:US
Mailing Address - Phone:309-762-9711
Mailing Address - Fax:309-762-9747
Practice Address - Street 1:1634 AVENUE OF THE CITIES
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-4860
Practice Address - Country:US
Practice Address - Phone:309-762-9711
Practice Address - Fax:309-762-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118384208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118384OtherLICENSE