Provider Demographics
NPI:1982852877
Name:ANANE-SEFAH, JASON M (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:ANANE-SEFAH
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 1:303 NORTH KUMPF BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605
Mailing Address - Country:US
Mailing Address - Phone:309-676-5546
Mailing Address - Fax:309-676-5045
Practice Address - Street 1:303 NORTH KUMPF BOULEVARD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605
Practice Address - Country:US
Practice Address - Phone:309-676-5546
Practice Address - Fax:309-676-5045
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.123697207X00000X, 207XS0106X
VA0101245826207X00000X, 207XS0106X
OH35093991207X00000X, 207XS0106X
MN103882207XS0106X
MN51034207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN400000061Medicare PIN