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General NPI Number Information
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NPI Number | 1629245527
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Entity Type | Organization
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Legal Business Name | MICHAEL P. VERCIMAK MDSC
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Dates
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Enumeration Date | 05/11/2008
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Last Update Date | 06/07/2010
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Provider Practice Location Address
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Address Line | 1311 MEMORIAL DR SUITE 700
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City | MENDOTA
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State | IL
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Zip | 61342-1495
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Country | US
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Telephone | 815-539-3831
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Fax | 815-538-4202
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Provider Business Mailing Address
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Address Line | 1311 MEMORIAL DR SUITE 700
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City | MENDOTA
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State | IL
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Zip | 61342-1495
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Country | US
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Telephone | 815-539-3831
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Fax | 815-538-4202
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL PETER VERCIMAK
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Credential |
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Telephone | 815-539-3831
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036067743
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License Number State | IL
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