Healthcare Provider Details

I. General information

NPI: 1629096359
Provider Name (Legal Business Name): MICHAEL J WALTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6812 STATE ROUTE 162 STE 202
MARYVILLE IL
62062-8562
US

IV. Provider business mailing address

6810 STATE ROUTE 162 BOX 215
MARYVILLE IL
62062
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-6844
  • Fax: 618-288-6852
Mailing address:
  • Phone: 618-391-6495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number103849
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number103849
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: