Provider Demographics
NPI:1811262728
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:PRESIDENT
Authorized Official - Prefix:DR
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:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-0649
Mailing Address - Country:US
Mailing Address - Phone:618-259-3321
Mailing Address - Fax:
Practice Address - Street 1:1702 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1898
Practice Address - Country:US
Practice Address - Phone:618-259-3321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009545111N00000X
IL038004303111N00000X
IL36048379208VP0014X, 2081P2900X
IL70004750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL477779OtherHEALTHLINK
224252OtherGHP
IL038009545Medicaid
IL210609OtherMEDICARE ILLINOIS
IL5933000001OtherMEDICARE P-TAN
IL04232007OtherBCBS ILLINOIS
IL038009545Medicaid
IL210609OtherMEDICARE ILLINOIS