Healthcare Provider Details

I. General information

NPI: 1700107216
Provider Name (Legal Business Name): OBHG ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

777 LOWNDES HILL RD BLDG 1
GREENVILLE SC
29607-2131
US

V. Phone/Fax

Practice location:
  • Phone: 800-967-2289
  • Fax: 864-627-9920
Mailing address:
  • Phone: 800-967-2289
  • Fax: 864-627-9920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LESTER C JURGENS
Title or Position: CEO
Credential: M.D.
Phone: 800-967-2289