Healthcare Provider Details

I. General information

NPI: 1477535284
Provider Name (Legal Business Name): KORNELIA G. JUERGENSEN MD, PHD, ABFP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KORNELIA GROSSKURTH MD

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2559 E 2450TH RD
MARSEILLES IL
61341-9749
US

IV. Provider business mailing address

2559 E 2450TH RD PO BOX 249
MARSEILLES IL
61341-9749
US

V. Phone/Fax

Practice location:
  • Phone: 815-795-5591
  • Fax: 815-795-5591
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number036104391
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-104391
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: