Healthcare Provider Details

I. General information

NPI: 1770946204
Provider Name (Legal Business Name): OB PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 CROSS ST THIRD FLOOR SUITE 3181
SHILOH IL
62269-2988
US

IV. Provider business mailing address

4500 MEMORIAL DRIVE MEMORIAL HOSPITAL MEDICAL AFFAIRS CREDENTIALING DEPT
BELLEVILLE IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-4644
  • Fax:
Mailing address:
  • Phone: 618-257-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES B DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-257-4644