Provider Demographics
NPI:1235122623
Name:REXROAT, MAX RONALD (DPM)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:RONALD
Last Name:REXROAT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455
Mailing Address - Country:US
Mailing Address - Phone:309-837-3964
Mailing Address - Fax:309-837-3966
Practice Address - Street 1:437 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455
Practice Address - Country:US
Practice Address - Phone:309-837-3964
Practice Address - Fax:309-837-3966
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK32326Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
T35845Medicare UPIN