Basic Information
| Provider Information | |||||||||
| NPI: | 1689629107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIEFKEN | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 HEALTH CARE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186642531 | ||||||||
| FaxNumber: | 6186642553 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HEALTH CARE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186642531 | ||||||||
| FaxNumber: | 6186642553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
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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 | 208000000X | 036088335 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | 036088335 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 036088335 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 193400000X | 01 | IL | TAXONOMYNCODE | OTHER |