Provider Demographics
NPI:1669451134
Name:STAGGENBORG, JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:STAGGENBORG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SPRING FOREST RD STE 130
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-873-9533
Mailing Address - Fax:844-454-0171
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN55500207L00000X
IL036086326207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086326OtherBC OF IL
IL036086326Medicaid
ILF63164Medicare UPIN
IL036086326OtherBC OF IL