Healthcare Provider Details

I. General information

NPI: 1376530949
Provider Name (Legal Business Name): JOHN J BOEREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W LINCOLN ST SUITE 300
BELLEVILLE IL
62220-1902
US

IV. Provider business mailing address

311 W LINCOLN ST SUITE 300
BELLEVILLE IL
62220-1902
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2566
  • Fax: 618-234-5650
Mailing address:
  • Phone: 618-234-2566
  • Fax: 618-234-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: