Healthcare Provider Details

I. General information

NPI: 1811262728
Provider Name (Legal Business Name): JERSEYVILLE PAIN MANAGEMENT CENTER, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 VAUGHN RD
WOOD RIVER IL
62095-1898
US

IV. Provider business mailing address

PO BOX 649
WOOD RIVER IL
62095-0649
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-3321
  • Fax:
Mailing address:
  • Phone: 618-259-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009545
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038004303
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number36048379
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number70004750
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number36048379
License Number StateIL

VIII. Authorized Official

Name: DR. JAMES A BRIGGS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 618-259-3321