Provider Demographics
NPI:1326127739
Name:MAX R REXROAT, DPM, LTD
Entity Type:Organization
Organization Name:MAX R REXROAT, DPM, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:R
Authorized Official - Last Name:REXROAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-837-3964
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-002507213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT35845Medicare UPIN
IL214328Medicare ID - Type UnspecifiedMEDICARE GROUP