Provider Demographics
NPI:1073611760
Name:JOSEFSON, REBECCA J (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:JOSEFSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:J
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:320 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4665
Mailing Address - Country:US
Mailing Address - Phone:217-877-9117
Mailing Address - Fax:217-877-3081
Practice Address - Street 1:320 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4665
Practice Address - Country:US
Practice Address - Phone:217-877-9117
Practice Address - Fax:217-877-3081
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110198208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860004Medicare NSC
ILI15826Medicare UPIN
I15826Medicare UPIN
ILIL3270030Medicare PIN