Provider Demographics
NPI:1629245527
Name:MICHAEL P. VERCIMAK MDSC
Entity Type:Organization
Organization Name:MICHAEL P. VERCIMAK MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:VERCIMAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-539-3831
Mailing Address - Street 1:1311 MEMORIAL DR
Mailing Address - Street 2:SUITE 700
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 1:1311 MEMORIAL DR
Practice Address - Street 2:SUITE 700
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-11
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067743208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL717080Medicare PIN
ILC45903Medicare UPIN