Provider Demographics
NPI:1285600247
Name:BACK PAIN CENTER, INC.
Entity type:Organization
Organization Name:BACK PAIN CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-233-4200
Mailing Address - Street 1:2516 MASCOUTAH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3468
Mailing Address - Country:US
Mailing Address - Phone:618-233-4200
Mailing Address - Fax:618-233-3428
Practice Address - Street 1:2516 MASCOUTAH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3468
Practice Address - Country:US
Practice Address - Phone:618-233-4200
Practice Address - Fax:618-233-3428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILY10615Medicare UPIN
IL209049Medicare ID - Type UnspecifiedMEDICARE NUMBER