Provider Demographics
NPI:1477514958
Name:POTTER, ORIE R (PAC MPAS)
Entity Type:Individual
Prefix:MR
First Name:ORIE
Middle Name:R
Last Name:POTTER
Suffix:
Gender:M
Credentials:PAC MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:OQUAWKA
Mailing Address - State:IL
Mailing Address - Zip Code:61469-0198
Mailing Address - Country:US
Mailing Address - Phone:309-867-2202
Mailing Address - Fax:309-867-3205
Practice Address - Street 1:1400 E CARROLL
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455
Practice Address - Country:US
Practice Address - Phone:309-833-2500
Practice Address - Fax:309-833-1760
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001876363A00000X
IL085000614363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371352599001Medicaid
IL141815Medicare Oscar/Certification
IL141051Medicare Oscar/Certification
IL141040Medicare Oscar/Certification
IL371352599001Medicaid