Basic Information
| Provider Information | |||||||||
| NPI: | 1831178573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEFFREY F FULLENKAMP DO LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689 | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600450689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476152200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 17TH ST | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612015351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097795000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | FULLENKAMP | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3097629711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2994418 | 05 | IA | MEDICAID | 3994418 | 05 | IA | MEDICAID |