Provider Demographics
NPI:1093772311
Name:WALL, MICHAEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-5690
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:241 W WEAVER RD
Practice Address - Street 2:STE 145C
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9799
Practice Address - Country:US
Practice Address - Phone:217-876-5200
Practice Address - Fax:217-876-5205
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16383Medicare UPIN
IL036071267Medicaid
ILK05344Medicare ID - Type Unspecified
IL256510159Medicare PIN