Provider Demographics
NPI:1386637106
Name:NELSON, NEIL R (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:R
Last Name:NELSON
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 1:8 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-2000
Mailing Address - Country:US
Mailing Address - Phone:217-784-8580
Mailing Address - Fax:217-784-8586
Practice Address - Street 1:8 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-2000
Practice Address - Country:US
Practice Address - Phone:217-784-8580
Practice Address - Fax:217-784-8586
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5248OtherNGS
IL363964866001 1Medicaid
IL036085035 1Medicaid
IL143944Medicare Oscar/Certification
ILIL5248Medicare PIN
IL347270Medicare PIN
ILF83101Medicare UPIN
IL363964866001 1Medicaid