Healthcare Provider Details

I. General information

NPI: 1073655676
Provider Name (Legal Business Name): JAMES MURRAY JEFFRIES III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 N GLEN PARK PLACE RD
PEORIA IL
61614-4676
US

IV. Provider business mailing address

4909 N GLEN PARK PLACE RD
PEORIA IL
61614-4676
US

V. Phone/Fax

Practice location:
  • Phone: 309-674-7546
  • Fax: 309-282-0500
Mailing address:
  • Phone: 309-674-7546
  • Fax: 309-282-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036.131119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: