Healthcare Provider Details

I. General information

NPI: 1891365391
Provider Name (Legal Business Name): KASIEMOBI BERNICE OKONKWO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 210
ALTON IL
62002-6704
US

IV. Provider business mailing address

4 MEMORIAL DR STE 210
ALTON IL
62002-6704
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-5905
  • Fax: 618-463-5935
Mailing address:
  • Phone: 618-463-5905
  • Fax: 618-463-5935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10077024
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036171380
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036171380
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: