Provider Demographics
NPI:1770646515
Name:JOSEPH, M T (MD FACC)
Entity Type:Individual
Prefix:DR
First Name:M
Middle Name:T
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:MD FACC
Other - Prefix:
Other - First Name:MELETH
Other - Middle Name:THOMMY
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3331 W DEYOUNG ST
Mailing Address - Street 2:STE 100
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5896
Mailing Address - Country:US
Mailing Address - Phone:618-998-7600
Mailing Address - Fax:618-997-6680
Practice Address - Street 1:3331 W DEYOUNG ST
Practice Address - Street 2:STE 100
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5896
Practice Address - Country:US
Practice Address - Phone:618-998-7600
Practice Address - Fax:618-997-3630
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045640207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
026849200OtherFEDERAL BLACK LUNG
IL036045640Medicaid
IL0010000066OtherBCBS OF IL
ILK46805OtherINDIVIDUAL PTAN
ILK46805OtherINDIVIDUAL PTAN
IL036045640Medicaid
ILD10778Medicare UPIN