Provider Demographics
NPI:1477535284
Name:JUERGENSEN, KORNELIA G (MD, PHD, ABFP)
Entity Type:Individual
Prefix:DR
First Name:KORNELIA
Middle Name:G
Last Name:JUERGENSEN
Suffix:
Gender:F
Credentials:MD, PHD, ABFP
Other - Prefix:DR
Other - First Name:KORNELIA
Other - Middle Name:
Other - Last Name:GROSSKURTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2559 E 2450TH RD
Mailing Address - Street 2:PO BOX 249
Mailing Address - City:MARSEILLES
Mailing Address - State:IL
Mailing Address - Zip Code:61341-9749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2559 E 2450TH RD
Practice Address - Street 2:
Practice Address - City:MARSEILLES
Practice Address - State:IL
Practice Address - Zip Code:61341-9749
Practice Address - Country:US
Practice Address - Phone:815-795-5591
Practice Address - Fax:815-795-5591
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104391173000000X
IL036-104391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104391Medicaid
MO1477535284Medicaid
MO137710004OtherMEDICARE IND #
MO1477535284Medicaid
MO137710004OtherMEDICARE IND #
IL211622Medicare ID - Type Unspecified
ILP00380331Medicare ID - Type UnspecifiedRR INDIVIDUAL