Provider Demographics
NPI:1043453707
Name:B C STUFFLEBAM, MD, LLC
Entity type:Organization
Organization Name:B C STUFFLEBAM, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:STUFFLEBAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-533-0727
Mailing Address - Street 1:629 SABLE DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-4472
Mailing Address - Country:US
Mailing Address - Phone:618-533-0727
Mailing Address - Fax:618-533-1464
Practice Address - Street 1:629 SABLE DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-4472
Practice Address - Country:US
Practice Address - Phone:618-533-0727
Practice Address - Fax:618-533-1464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360588472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42550Medicare UPIN