Provider Demographics
NPI:1386660553
Name:OAK SPRING MEDICAL GROUP INC
Entity Type:Organization
Organization Name:OAK SPRING MEDICAL GROUP INC
Other - Org Name:JENNIFER C BARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEBRULER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-968-2800
Mailing Address - Street 1:131 E PARK AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2800
Mailing Address - Country:US
Mailing Address - Phone:847-968-2800
Mailing Address - Fax:847-968-2801
Practice Address - Street 1:131 E PARK AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2800
Practice Address - Country:US
Practice Address - Phone:847-968-2800
Practice Address - Fax:847-968-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H81367Medicare UPIN
212265Medicare ID - Type Unspecified