Provider Demographics
NPI:1548368475
Name:ADVANCED PAIN INTERVENTION SC
Entity type:Organization
Organization Name:ADVANCED PAIN INTERVENTION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROSCHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DABPM
Authorized Official - Phone:815-387-1012
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-0109
Mailing Address - Country:US
Mailing Address - Phone:815-387-1012
Mailing Address - Fax:815-381-0776
Practice Address - Street 1:534 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5076
Practice Address - Country:US
Practice Address - Phone:815-387-1012
Practice Address - Fax:815-381-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097335Medicaid
IL213192Medicare ID - Type Unspecified
IL036097335Medicaid