Healthcare Provider Details

I. General information

NPI: 1275642233
Provider Name (Legal Business Name): JOHN D. MELLINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST 5TH FLOOR
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19638
SPRINGFIELD IL
62794-9638
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-5878
  • Fax: 217-545-0040
Mailing address:
  • Phone: 217-545-5878
  • Fax: 217-545-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-124378
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: