1730190018 NPI number — DAVID N. PFOHL, MD, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730190018 NPI number — DAVID N. PFOHL, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID N. PFOHL, MD, 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:
DBA ELDERMED SERVICES
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:
1730190018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 968
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62269-0968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-624-1860
Provider Business Mailing Address Fax Number:
618-624-1863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1512 N GREEN MOUNT RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62269-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-624-1860
Provider Business Practice Location Address Fax Number:
618-624-1863
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEITH
Authorized Official First Name:
JERRIE
Authorized Official Middle Name:
K
Authorized Official Title or Position:
BUSINESS ADVISOR
Authorized Official Telephone Number:
618-779-5508

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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