1477535284 NPI number — DR. KORNELIA G. JUERGENSEN MD, PHD, ABFP

Table of content: DR. KORNELIA G. JUERGENSEN MD, PHD, ABFP (NPI 1477535284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477535284 NPI number — DR. KORNELIA G. JUERGENSEN MD, PHD, ABFP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUERGENSEN
Provider First Name:
KORNELIA
Provider Middle Name:
G.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD, ABFP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROSSKURTH
Provider Other First Name:
KORNELIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1477535284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2559 E 2450TH RD
Provider Second Line Business Mailing Address:
PO BOX 249
Provider Business Mailing Address City Name:
MARSEILLES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61341-9749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2559 E 2450TH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSEILLES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61341-9749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-795-5591
Provider Business Practice Location Address Fax Number:
815-795-5591
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  036104391 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036-104391 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036104391 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1477535284 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 137710004 . This is a "MEDICARE IND #" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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