Provider Demographics
NPI:1710968813
Name:SIEBERT, PHILIP G (DPM)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:G
Last Name:SIEBERT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3806
Mailing Address - Country:US
Mailing Address - Phone:217-523-4539
Mailing Address - Fax:217-523-5026
Practice Address - Street 1:102 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3806
Practice Address - Country:US
Practice Address - Phone:217-523-4539
Practice Address - Fax:217-523-5026
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL112286OtherHEALTHLINK PROVIDER NUMBE
IL60115587OtherBC/BS PROVIDER NUMBER
IL112286OtherHEALTHLINK PROVIDER NUMBE