Provider Demographics
NPI:1386668218
Name:ARENDELL, JEFFREY D (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:ARENDELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6713 STONERIDGE EST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2905
Mailing Address - Country:US
Mailing Address - Phone:618-476-1967
Mailing Address - Fax:
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-798-6300
Practice Address - Fax:618-798-3716
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086735207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3932056OtherBLUE SHIELD
IL036086735-3Medicaid
IL214881015Medicare PIN
IL036086735-3Medicaid