Healthcare Provider Details

I. General information

NPI: 1003435215
Provider Name (Legal Business Name): LOUIS JAY LEVINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LOU JAY LEVINE MD

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD
O FALLON IL
62269-1281
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD
O FALLON IL
62269-1281
US

V. Phone/Fax

Practice location:
  • Phone: 618-641-5803
  • Fax: 618-607-5116
Mailing address:
  • Phone: 618-641-5803
  • Fax: 618-607-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036180033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: