Healthcare Provider Details

I. General information

NPI: 1710140645
Provider Name (Legal Business Name): JOSHUA A. NIEBRUEGGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 MEMORIAL DR STE. 340
BELLEVILLE IL
62226-5372
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1844
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-6200
  • Fax: 618-257-6679
Mailing address:
  • Phone: 510-851-7423
  • Fax: 510-879-9120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036127134
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036127134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: