Provider Demographics
NPI:1629386586
Name:OB PRACTICE, LLC
Entity Type:Organization
Organization Name:OB PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-257-4644
Mailing Address - Street 1:4500 MEMORIAL DR
Mailing Address - Street 2:MEDICAL AFFAIRS CREDENTIALING DEPARTMENT
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5360
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:618-257-6946
Practice Address - Street 1:4600 MEMORIAL DRIVE
Practice Address - Street 2:STE. 400
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-234-2390
Practice Address - Fax:618-234-9936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OB PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4503Medicare PIN