Healthcare Provider Details

I. General information

NPI: 1740702703
Provider Name (Legal Business Name): JONATHAN RAPHAEL SCHWEBER MB.BCH.BAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDREN'S PL CB 8116
ST LOUIS MO
63110
US

IV. Provider business mailing address

1617 S LINCOLN AVE
SPRINGFIELD IL
62704-3418
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6095
  • Fax: 314-454-2561
Mailing address:
  • Phone: 217-899-5004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2020018961
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: