Jeffrey R Barra, M.D.
Individual provider Active NPI Family Medicine Physician · Mount Vernon, IL
NPI 1679548713 · NPPES record last updated May 13, 2015
Key facts
- NPI
- 1679548713
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 036107295 (IL)
- Practice address
- 5100 Lake Ter NE
Suite WC
Mount Vernon, IL 62864-9665 - Phone
- (618) 899-5001
- Fax
- (618) 242-5152
- NPI assigned
- Feb 22, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040105000107 | IL | Practitioner - Family Practice | 4789583279 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Premise Health of Illinois Medical PC | Current |
Accepting new patients | |
| Premise Health of Illinois Medical PC | Current |
Accepting new patients | |
| Premise Health of Illinois Medical, PC | Past | Accepting new patients |
Locations
16906 Collection Ctr Dr
Chicago, IL 60693
5100 Lake Ter NE
Ste Wc
Mount Vernon, IL 62864
Phone (618) 899-5001
5100 Lake Ter NE
Mount Vernon, IL 62864
Phone (618) 244-8793
5500 Maryland Way
Ste 200
Brentwood, TN 37027
Phone (615) 577-4927
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036107295 | IL | Yes |
Addresses
Primary practice location
5100 Lake Ter NE
Suite WC
Mount Vernon, IL 62864-9665
Mailing address
5100 Lake Ter NE
Suite WC
Mount Vernon, IL 62864-9665
Phone (618) 899-5001
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036107295 | Medicaid | IL |
Other providers in Mount Vernon, IL
- Whitney Baldridge
- Allison Baldwin
- Julia W Balsover
- Krista Barber
- Teresa L Barnfield
- Becca Barth
- Amy Elizabeth Barton
- Jennifer K Bass
- Amanda Lyn Bathon
- Lindsey Bearden
All providers in Mount Vernon, IL · Family Medicine Physician in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 13, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.