Healthcare Provider Details

I. General information

NPI: 1972789238
Provider Name (Legal Business Name): JASON MICHAEL SEIBLY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 08/17/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 S MERCER AVE
BLOOMINGTON IL
61701-7107
US

IV. Provider business mailing address

611 W. PARK ST FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036119851
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: