Provider Demographics
NPI:1124532593
Name:CHICAGO PAIN MEDICINE CENTER
Entity type:Organization
Organization Name:CHICAGO PAIN MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIESFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-868-6824
Mailing Address - Street 1:1044 N FRANCISCO AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2743
Mailing Address - Country:US
Mailing Address - Phone:773-868-6824
Mailing Address - Fax:
Practice Address - Street 1:6307 S STEWART AVE STE 205
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3116
Practice Address - Country:US
Practice Address - Phone:773-868-6824
Practice Address - Fax:773-868-6828
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICAGO PAIN MEDICINE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-21
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IL036.086023208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01605512OtherBCBS
IL036008623Medicaid