Healthcare Provider Details

I. General information

NPI: 1154394484
Provider Name (Legal Business Name): MICHAEL J MCFADDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N RUSH ST
STOCKTON IL
61085-1010
US

IV. Provider business mailing address

421 W EXCHANGE ST PO BOX 268
FREEPORT IL
61032-0268
US

V. Phone/Fax

Practice location:
  • Phone: 815-947-3211
  • Fax: 815-947-3236
Mailing address:
  • Phone: 815-599-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036106757
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: