Provider Demographics
NPI:1760477376
Name:CHILDERS, ROBERT D (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:CHILDERS
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:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-0028
Mailing Address - Country:US
Mailing Address - Phone:618-498-8470
Mailing Address - Fax:618-498-8488
Practice Address - Street 1:400 MAPLE SUMMIT RD
Practice Address - Street 2:STE 300
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2028
Practice Address - Country:US
Practice Address - Phone:618-498-8470
Practice Address - Fax:618-498-8488
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01093287A208800000X
IL036073486208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073486Medicaid
MO2822OtherBLUE CROSS BLUE SHIELD
IL0006000528OtherBLUE CROSS BLUE SHIELD
IL340014235OtherRAILROAD MEDICARE
ILK03232Medicare PIN
ILB18395Medicare UPIN