Provider Demographics
NPI:1447276480
Name:MEDICAL PAIN MANAGEMENT SERVICES, LTD.
Entity type:Organization
Organization Name:MEDICAL PAIN MANAGEMENT SERVICES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-877-4848
Mailing Address - Street 1:1235 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-397-8400
Mailing Address - Fax:815-229-0050
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-397-8400
Practice Address - Fax:815-229-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-005593261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL970470Medicare ID - Type UnspecifiedGROUP
CK0355Medicare PIN