Provider Demographics
NPI:1710914064
Name:MULCONREY, DANIEL SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SCOTT
Last Name:MULCONREY
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 1:6000 N ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3294
Mailing Address - Country:US
Mailing Address - Phone:309-691-1400
Mailing Address - Fax:309-689-7081
Practice Address - Street 1:6000 N ALLEN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3294
Practice Address - Country:US
Practice Address - Phone:309-691-1400
Practice Address - Fax:309-689-7081
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-118429174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118429Medicaid
IL1291050001Medicare NSC
IL036118429Medicaid