Provider Demographics
NPI:1992773311
Name:ALFREY, EDWARD JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:ALFREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BON AIR ROAD
Mailing Address - Street 2:STE. 101
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939
Mailing Address - Country:US
Mailing Address - Phone:415-924-2515
Mailing Address - Fax:415-924-2661
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:ROOM 1700
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4909
Practice Address - Country:US
Practice Address - Phone:217-545-5878
Practice Address - Fax:217-545-1793
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114340204F00000X
CAG72742204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114340Medicaid
ILK22727Medicare PIN
IL036114340Medicaid
F04534Medicare UPIN