Provider Demographics
NPI:1801061650
Name:CENTER FOR PAIN MANAGEMENT & REHAB S. C .
Entity type:Organization
Organization Name:CENTER FOR PAIN MANAGEMENT & REHAB S. C .
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YIBING
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-696-3300
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 117
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5095
Mailing Address - Country:US
Mailing Address - Phone:309-689-8888
Mailing Address - Fax:309-689-8410
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 117
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5095
Practice Address - Country:US
Practice Address - Phone:309-689-8888
Practice Address - Fax:309-689-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113585261QR0400X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DN7761OtherRR MEDICARE
IL216706Medicare PIN