Provider Demographics
NPI:1942227863
Name:SOUTHERN ILLINOIS PAIN MANAGEMENT
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:JUERGENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-993-5859
Mailing Address - Street 1:3905 W ERNESTINE DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5800
Mailing Address - Country:US
Mailing Address - Phone:618-993-5859
Mailing Address - Fax:618-997-1588
Practice Address - Street 1:3905 W ERNESTINE DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5800
Practice Address - Country:US
Practice Address - Phone:618-993-5859
Practice Address - Fax:618-997-1588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4331030001Medicare NSC
IL530750Medicare PIN