Provider Demographics
NPI:1053595538
Name:LOETHEN, PAUL E (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:E
Last Name:LOETHEN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1414 CROSS STREET
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2998
Mailing Address - Country:US
Mailing Address - Phone:618-277-7400
Mailing Address - Fax:618-277-7422
Practice Address - Street 1:1414 CROSS STREET
Practice Address - Street 2:SUITE 330
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2998
Practice Address - Country:US
Practice Address - Phone:618-277-7400
Practice Address - Fax:618-277-7422
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2024-03-20
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Provider Licenses
StateLicense IDTaxonomies
IL036122761208600000X
IL125048399208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL384230005Medicare UPIN