Basic Information
Provider Information | |||||||||
NPI: | 1710147236 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEFFREY S BOBERG DPM LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ANKLE & FOOT SURGEONS OF THE MIDWEST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 180 S 3RD ST | ||||||||
Address2: | STE 103 | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622201952 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182367444 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 180 S 3RD ST | ||||||||
Address2: | STE 103 | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622201952 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182367444 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2008 | ||||||||
LastUpdateDate: | 07/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOBERG | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 6182367444 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016004233 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.