Healthcare Provider Details

I. General information

NPI: 1992773311
Provider Name (Legal Business Name): EDWARD JOHN ALFREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST ROOM 1700
SPRINGFIELD IL
62702-4909
US

IV. Provider business mailing address

5 BON AIR ROAD STE. 101
LARKSPUR CA
94939
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-5878
  • Fax: 217-545-1793
Mailing address:
  • Phone: 415-924-2515
  • Fax: 415-924-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number036-114340
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberG72742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: