Provider Demographics
NPI:1922026673
Name:JUERGENS, PAUL BRIAN (MD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:BRIAN
Last Name:JUERGENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3441
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3441
Mailing Address - Country:US
Mailing Address - Phone:573-575-6440
Mailing Address - Fax:618-942-7399
Practice Address - Street 1:900 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1233
Practice Address - Country:US
Practice Address - Phone:573-575-6440
Practice Address - Fax:618-942-7399
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067084208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010022254OtherBLUE CROSS BLUE SHIELD
ILCH1495OtherRAILROAD MEDICARE
IL036067084Medicaid
ILL68041Medicare PIN
IL0010022254OtherBLUE CROSS BLUE SHIELD