Healthcare Provider Details

I. General information

NPI: 1235339474
Provider Name (Legal Business Name): SUSAN E KOBER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 3RD ST
BELLEVILLE IL
62220-1915
US

IV. Provider business mailing address

106 MIDDLEGATE LN
COLLINSVILLE IL
62234-5515
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax: 618-222-4753
Mailing address:
  • Phone: 618-343-0825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: