Provider Demographics
NPI:1639280290
Name:JEFFREY S BOBERG DPM LLC
Entity Type:Organization
Organization Name:JEFFREY S BOBERG DPM LLC
Other - Org Name:ANKLE & FOOT SURGEONS OF THE MIDWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:314-739-7100
Mailing Address - Street 1:12255 DE PAUL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:314-739-7100
Mailing Address - Fax:314-739-3199
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:STE 100
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-739-7100
Practice Address - Fax:314-739-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000570213ES0103X
IL016004233213ES0103X
MO2005026457213ES0103X
IL016005217213ES0103X
MO2003013610213ES0103X
IL016005131213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500008107Medicaid
ILDC4793OtherRAILROAD MEDICARE
MODA9953OtherRAILROAD MEDICARE
IL207965Medicare PIN
ILDC4793OtherRAILROAD MEDICARE
MO5031350001Medicare NSC