Basic Information
| Provider Information | |||||||||
| NPI: | 1356581730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AXELBAUM | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MIROWITZ | ||||||||
| OtherFirstName: | JAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 211 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6186415806 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6186415806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2009 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2002001971 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2002001971 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 036138448 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1356581730 | 05 | MO | MEDICAID |