Provider Demographics
NPI:1245222736
Name:WALSH, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:WALSH
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 1:903 129TH INFANTRY DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3171
Mailing Address - Country:US
Mailing Address - Phone:815-725-2653
Mailing Address - Fax:815-744-3232
Practice Address - Street 1:903 129TH INFANTRY DR
Practice Address - Street 2:SUITE 400
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3171
Practice Address - Country:US
Practice Address - Phone:815-725-2653
Practice Address - Fax:815-744-3232
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-068704174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00060766OtherPALMETTO RR MEDICARE
ILE56123Medicare UPIN
ILK00770Medicare PIN
ILP00060766OtherPALMETTO RR MEDICARE