1639280290 NPI number — JEFFREY S BOBERG DPM LLC

Table of content: (NPI 1639280290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639280290 NPI number — JEFFREY S BOBERG DPM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY S BOBERG DPM LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ANKLE & FOOT SURGEONS OF THE MIDWEST
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639280290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12255 DE PAUL DR
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
BRIDGETON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63044-2510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-739-7100
Provider Business Mailing Address Fax Number:
314-739-3199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DE PAUL DR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-739-7100
Provider Business Practice Location Address Fax Number:
314-739-3199
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOBERG
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
314-739-7100

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  000570 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: 016004233 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 2005026457 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 016005217 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 2003013610 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 016005131 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500008107 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: DC4793 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DA9953 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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