Basic Information
| Provider Information | |||||||||
| NPI: | 1629386586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OB PRACTICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | MEDICAL AFFAIRS CREDENTIALING DEPARTMENT | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182574644 | ||||||||
| FaxNumber: | 6182576946 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 MEMORIAL DRIVE | ||||||||
| Address2: | STE. 400 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342390 | ||||||||
| FaxNumber: | 6182349936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6182574644 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OB PRACTICE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.