Provider Demographics
NPI:1689622250
Name:MEISENBACH, JOSEPH A (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:MEISENBACH
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 1:455 W. COURT ST.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3693
Mailing Address - Country:US
Mailing Address - Phone:815-935-1161
Mailing Address - Fax:815-932-3678
Practice Address - Street 1:455 W. COURT ST.
Practice Address - Street 2:SUITE 202
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3693
Practice Address - Country:US
Practice Address - Phone:815-935-1161
Practice Address - Fax:815-932-3678
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053943207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053943Medicaid
C45044Medicare UPIN
IL655050Medicare ID - Type Unspecified