Healthcare Provider Details

I. General information

NPI: 1174591010
Provider Name (Legal Business Name): GEORGE E MIGUEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N HAMMES AVE STE 108
JOLIET IL
60435-6688
US

IV. Provider business mailing address

210 N HAMMES AVE STE 108
JOLIET IL
60435-6688
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-8977
  • Fax: 815-744-8253
Mailing address:
  • Phone: 815-744-8253
  • Fax: 815-744-8977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036098565
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: