Healthcare Provider Details

I. General information

NPI: 1619293149
Provider Name (Legal Business Name): GREGORY THOMAS BISMACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N MAPLE ST
EFFINGHAM IL
62401-2006
US

IV. Provider business mailing address

801 SWARTHMORE LN
UNIVERSITY CITY MO
63130-3620
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-2121
  • Fax:
Mailing address:
  • Phone: 248-808-2485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2022010983
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036155470
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301097035
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.155470
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: