Active NPI
Pothen Jacob, MD
- Pediatrics Physician
- E St Louis, IL
National Provider Identifier
1376640474
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 3648725
- Practice address
- 4601 State St
Suite #210
E St Louis, IL 62205-1359 - Phone
- (618) 874-3700
- Fax
- (618) 874-5031
- NPI assigned
- Sep 20, 2006
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 3648725 | IL | Primary |
Addresses
Primary practice location
4601 State St
Suite #210
E St Louis, IL 62205-1359
Mailing address
PO Box 2228
4601 State St Suite #210
E St Louis, IL 62205-1359
Phone (618) 874-3700
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3648725 | IL | MD | Pediatrics Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158710400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1376640474",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 2228",
"address_2": "4601 STATE ST SUITE #210",
"city": "E ST LOUIS",
"state": "IL",
"postal_code": "622051359",
"telephone_number": "618-874-3700",
"fax_number": "618-874-5031"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4601 STATE ST",
"address_2": "SUITE #210",
"city": "E ST LOUIS",
"state": "IL",
"postal_code": "622051359",
"telephone_number": "618-874-3700",
"fax_number": "618-874-5031"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACOB",
"first_name": "POTHEN",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-09-20",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "IL",
"license": "3648725",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in E St Louis, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.