Provider Demographics
NPI:1366500852
Name:VERCIMAK, MICHAEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:VERCIMAK
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 1:1405 E 12TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-1495
Mailing Address - Country:US
Mailing Address - Phone:815-539-3831
Mailing Address - Fax:815-538-4202
Practice Address - Street 1:1405 E 12TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1495
Practice Address - Country:US
Practice Address - Phone:815-539-3831
Practice Address - Fax:815-538-4202
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067743208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005000301OtherBCBS
020002934OtherRR MEDICARE
020002934OtherPALMETTO
020002934OtherGBA
IL036067743Medicaid
IL717080Medicare ID - Type Unspecified
IL036067743Medicaid