Provider Demographics
NPI:1932115755
Name:PIERSON MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PIERSON MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-868-3309
Mailing Address - Street 1:1477 RING RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5459
Mailing Address - Country:US
Mailing Address - Phone:708-868-3309
Mailing Address - Fax:708-868-3321
Practice Address - Street 1:1477 RING RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5459
Practice Address - Country:US
Practice Address - Phone:708-868-3309
Practice Address - Fax:708-868-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088112174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088112Medicaid
IL01634224OtherBC/BS PROVIDER #
IL209178Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #
IL01634224OtherBC/BS PROVIDER #