Provider Demographics
NPI:1184829996
Name:THOMAS W. KUPFERER, D.O.
Entity Type:Organization
Organization Name:THOMAS W. KUPFERER, D.O.
Other - Org Name:DESOTO FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-687-2353
Mailing Address - Street 1:407 S CHESTNUT
Mailing Address - Street 2:PO BOX 104
Mailing Address - City:DESOTO
Mailing Address - State:IL
Mailing Address - Zip Code:62924-1400
Mailing Address - Country:US
Mailing Address - Phone:618-867-2703
Mailing Address - Fax:618-687-9511
Practice Address - Street 1:407 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:IL
Practice Address - Zip Code:62924-1400
Practice Address - Country:US
Practice Address - Phone:618-867-2703
Practice Address - Fax:618-867-2353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099723207Q00000X
IL036066913261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143890OtherMEDICARE RURAL HEALTH
IL039-00152OtherBCBS
IL=========001Medicaid
IL143890OtherMEDICARE RURAL HEALTH
ILC45819Medicare UPIN