MEDICARE: POTHEN JACOB MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	3648725	IL

General Provider Information

NPI Number	:	1376640474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	POTHEN JACOB MD

Provider Business Mailing Address
First Line	:	PO BOX 2228
Second Line	:	4601 STATE ST SUITE #210
City	:	E ST LOUIS
State	:	IL
Zip	:	62205-1359
Country	:	US
Telephone Number	:	618-874-3700
Fax Number	:	618-874-5031

Provider Business Practice Location Address
First Line	:	4601 STATE ST
Second Line	:	SUITE #210
City	:	E ST LOUIS
State	:	IL
Zip	:	62205-1359
Country	:	US
Telephone Number	:	618-874-3700
Fax Number	:	618-874-5031

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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Directions to “ POTHEN JACOB MD” Practice Location

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