Provider Demographics
NPI:1063470524
Name:JERSEYVILLE PAIN MANAGEMENT CENTER, S.C.
Entity Type:Organization
Organization Name:JERSEYVILLE PAIN MANAGEMENT CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-259-3321
Mailing Address - Street 1:P.O. BOX 649
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095
Mailing Address - Country:US
Mailing Address - Phone:618-259-3321
Mailing Address - Fax:618-259-3324
Practice Address - Street 1:1702 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095
Practice Address - Country:US
Practice Address - Phone:618-259-3321
Practice Address - Fax:618-259-3324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-618378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5933000001OtherMEDICARE DME
ILU89003Medicare UPIN
IL5933000001OtherMEDICARE DME
IL5933000001Medicare PIN
IL210609Medicare PIN