Healthcare Provider Details

I. General information

NPI: 1184829996
Provider Name (Legal Business Name): THOMAS W. KUPFERER, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S CHESTNUT ST
DE SOTO IL
62924-1400
US

IV. Provider business mailing address

407 S CHESTNUT PO BOX 104
DESOTO IL
62924-1400
US

V. Phone/Fax

Practice location:
  • Phone: 618-867-2703
  • Fax: 618-867-2353
Mailing address:
  • Phone: 618-867-2703
  • Fax: 618-687-9511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036099723
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number036066913
License Number StateIL

VIII. Authorized Official

Name: MRS. JANET L AUSTIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 618-687-2353