Provider Demographics
NPI:1154334779
Name:RX PAIN MANAGEMENT GROUP PC
Entity type:Organization
Organization Name:RX PAIN MANAGEMENT GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:YAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-247-2131
Mailing Address - Street 1:3405 S HALSTED STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6707
Mailing Address - Country:US
Mailing Address - Phone:773-247-2131
Mailing Address - Fax:773-247-3110
Practice Address - Street 1:3405 S HALSTED STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6707
Practice Address - Country:US
Practice Address - Phone:773-247-2131
Practice Address - Fax:773-247-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 208000000X
IL036088691207R00000X, 2081P2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088691Medicaid
IL1620404OtherBCBS
IL208573Medicare ID - Type UnspecifiedMEDICARE GROUP
ILK04746Medicare PIN
IL1620404OtherBCBS
IL208573Medicare UPIN
D15863Medicare UPIN
IL036088691Medicaid