Provider Demographics
NPI:1427141787
Name:PROEHL, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PROEHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:IL
Mailing Address - Zip Code:61747-7525
Mailing Address - Country:US
Mailing Address - Phone:815-842-3633
Mailing Address - Fax:815-844-6309
Practice Address - Street 1:107 TREMONT ST
Practice Address - Street 2:
Practice Address - City:HOPEDALE
Practice Address - State:IL
Practice Address - Zip Code:61747-7525
Practice Address - Country:US
Practice Address - Phone:309-449-4338
Practice Address - Fax:309-449-4880
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112475207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112475Medicaid
ILP00339522Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL833230Medicare ID - Type UnspecifiedGROUP #
ILCA2182Medicare ID - Type UnspecifiedRR GROUP #
I43829Medicare UPIN
ILK21844Medicare ID - Type UnspecifiedINDIVIDUAL #