Provider Demographics
NPI:1295728988
Name:BARNETT, JASON E (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:E
Last Name:BARNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6812 STATE ROUTE 162
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8553
Mailing Address - Country:US
Mailing Address - Phone:618-288-0044
Mailing Address - Fax:618-288-0066
Practice Address - Street 1:6812 STATE ROUTE 162
Practice Address - Street 2:SUITE 120
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8553
Practice Address - Country:US
Practice Address - Phone:618-288-0044
Practice Address - Fax:618-288-0066
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036104914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104914Medicaid
IL036104914004Medicaid
ILP00437778OtherRR MEDICARE
ILK13643Medicare ID - Type Unspecified
ILH38397Medicare UPIN
ILK37020Medicare PIN