Basic Information
| Provider Information | |||||||||
| NPI: | 1184690109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNUFFMAN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 10/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 44933 | WI | N | Allopathic & Osteopathic Physicians | General Practice | 207RA0201X | 44933 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207RA0201X | 036133088 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 34583000 | 05 | WI | MEDICAID |