Healthcare Provider Details

I. General information

NPI: 1154361921
Provider Name (Legal Business Name): DAVID G VERMILLION M D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 N DIVISION ST STE 201
MORRIS IL
60450-1183
US

IV. Provider business mailing address

1802 N DIVISION ST STE 201
MORRIS IL
60450-1183
US

V. Phone/Fax

Practice location:
  • Phone: 815-513-5625
  • Fax: 815-513-5624
Mailing address:
  • Phone: 815-513-5625
  • Fax: 815-513-5624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number208000000X
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number207R00000X
License Number StateIL

VIII. Authorized Official

Name: MARY M. SMITH
Title or Position: BILLER/CODER
Credential:
Phone: 815-942-5200