Healthcare Provider Details

I. General information

NPI: 1356430664
Provider Name (Legal Business Name): MEDICAL GROUP OF MACOMB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E GRANT ST STE 103
MACOMB IL
61455-3308
US

IV. Provider business mailing address

PO BOX 556
MACOMB IL
61455-0556
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-3536
  • Fax: 309-836-5729
Mailing address:
  • Phone: 309-833-3536
  • Fax: 309-836-5729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. DAVID MILLER
Title or Position: PRESIDENT
Credential: D.O.
Phone: 309-833-3536