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General NPI Number Information
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NPI Number | 1356430664
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Entity Type | Organization
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Legal Business Name | MEDICAL GROUP OF MACOMB, LLC
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 505 E GRANT ST STE 103
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City | MACOMB
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State | IL
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Zip | 61455-3308
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Country | US
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Telephone | 309-833-3536
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Fax | 309-836-5729
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Provider Business Mailing Address
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Address Line | PO BOX 556
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City | MACOMB
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State | IL
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Zip | 61455-0556
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Country | US
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Telephone | 309-833-3536
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Fax | 309-836-5729
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DAVID MILLER
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Credential | D.O.
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Telephone | 309-833-3536
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State | IL
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