Provider Demographics
NPI:1710147236
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:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
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:618-236-7444
Mailing Address - Street 1:180 S 3RD ST
Mailing Address - Street 2:STE 103
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1952
Mailing Address - Country:US
Mailing Address - Phone:618-236-7444
Mailing Address - Fax:
Practice Address - Street 1:180 S 3RD ST
Practice Address - Street 2:STE 103
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1952
Practice Address - Country:US
Practice Address - Phone:618-236-7444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004233213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5031350002Medicare NSC