Provider Demographics
NPI:1518172162
Name:SANGAMON COUNTY PAIN CENTER
Entity Type:Organization
Organization Name:SANGAMON COUNTY PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-698-5400
Mailing Address - Street 1:315 CHATHAM RD
Mailing Address - Street 2:STE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1497
Mailing Address - Country:US
Mailing Address - Phone:217-698-5400
Mailing Address - Fax:217-698-2800
Practice Address - Street 1:315 CHATHAM RD
Practice Address - Street 2:STE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1497
Practice Address - Country:US
Practice Address - Phone:217-698-5400
Practice Address - Fax:217-698-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08432010OtherBLUE CROSS BLUE SHIELD
IL208588Medicare ID - Type UnspecifiedPROVIDER #