| Southern Illinois Oral & Maxillofacial Surgery, Ltd. | |
|
2900 Frank Scott Pkwy W Suite 960 Belleville IL 62223-5000 | |
| (618) 233-8080 | |
| (618) 233-1192 |
| Full Name | Southern Illinois Oral & Maxillofacial Surgery, Ltd. |
|---|---|
| Speciality | Dentist |
| Location | 2900 Frank Scott Pkwy W, Belleville, Illinois |
| Authorized Official Name and Position | Michael R. Hesterberg (PRESIDENT) |
| Authorized Official Contact | 6182338080 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Illinois Oral & Maxillofacial Surgery, Ltd. 2900 Frank Scott Pkwy W Suite 960 Belleville IL 62223-5000 Ph: (618) 233-8080 | Southern Illinois Oral & Maxillofacial Surgery, Ltd. 2900 Frank Scott Pkwy W Suite 960 Belleville IL 62223-5000 Ph: (618) 233-8080 |
| NPI Number | 1538180617 |
|---|---|
| Provider Enumeration Date | 07/22/2006 |
| Last Update Date | 11/24/2014 |
| Medicare PECOS PAC ID | 7517146244 |
|---|---|
| Medicare Enrollment ID | O20110126000717 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1538180617 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | 021-001364 (Illinois) | Primary |
| Provider Name | Edgar J Breda |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1497742407 PECOS PAC ID: 9436338175 Enrollment ID: I20110126000896 |
| Provider Name | Michael R Hesterberg |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1184611212 PECOS PAC ID: 6800075540 Enrollment ID: I20110126000924 |
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