Provider Demographics
NPI:1184927303
Name:EVAN T BELFER MD SC
Entity type:Organization
Organization Name:EVAN T BELFER MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:BELFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-687-2319
Mailing Address - Street 1:801 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-1611
Mailing Address - Country:US
Mailing Address - Phone:618-687-2319
Mailing Address - Fax:618-684-3321
Practice Address - Street 1:801 N 14TH ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-1611
Practice Address - Country:US
Practice Address - Phone:618-687-2319
Practice Address - Fax:618-684-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107906261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL078338OtherHEALTH ALLIANCE
IL431741OtherHEALTHLINK
IL039-32006OtherBLUECROSS BLUESHIELD
IL614634500OtherDEPARTMENT OF LABOR
IL080191627OtherRAILROAD MEDICARE
IL036-107906Medicaid
IL039-32006OtherBLUECROSS BLUESHIELD