Healthcare Provider Details

I. General information

NPI: 1215317599
Provider Name (Legal Business Name): MICHAEL DEVISSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 08/23/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

V. Phone/Fax

Practice location:
  • Phone: 815-766-7334
  • Fax: 815-766-9768
Mailing address:
  • Phone: 815-766-7334
  • Fax: 815-766-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01081653A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036149046
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: