Basic Information
| Provider Information | |||||||||
| NPI: | 1255609574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JERSEYVILLE PAIN MANAGEMENT CENTER, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1702 VAUGHN RD | ||||||||
| Address2: | |||||||||
| City: | WOOD RIVER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620951898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182593321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHOMHIRUN | ||||||||
| AuthorizedOfficialFirstName: | BUD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6182593321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JERSEYVILLE PAIN MANAGEMENT CENTER, S.C. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.