Provider Demographics
NPI:1003022088
Name:RICHARD J SIEBERT, M.D.,S,C.
Entity Type:Organization
Organization Name:RICHARD J SIEBERT, M.D.,S,C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-234-8808
Mailing Address - Street 1:700 N WESTMORELAND RD STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1672
Mailing Address - Country:US
Mailing Address - Phone:847-234-8808
Mailing Address - Fax:
Practice Address - Street 1:700 N WESTMORELAND RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1672
Practice Address - Country:US
Practice Address - Phone:847-234-8808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4900663OtherBLUE SHIELD
IL315380Medicare ID - Type Unspecified