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NPI Code Detail

MEDICARE: DR. STONEWALL MCCUISTON JR. MD

MEDICARE: DR. STONEWALL MCCUISTON JR. MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician036074737IL
2208000000XPediatrics Physician036074737IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14623239OTHERILBLUE CROSS AND BLUE SHIELD OF ILLINOIS
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1720072143
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. STONEWALL MCCUISTON JR. MD
Provider Business Mailing Address
First Line : 375 N WALL ST STE P310
Second Line :
City : KANKAKEE
State : IL
Zip : 60901-3484
Country : US
Telephone Number : 815-933-0194
Fax Number : 815-936-3847
Provider Business Practice Location Address
First Line : 375 N WALL ST STE P310
Second Line :
City : KANKAKEE
State : IL
Zip : 60901-3484
Country : US
Telephone Number : 815-933-0194
Fax Number : 815-936-3847
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2005
Last Update Date : 03/29/2021

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