Provider Demographics
NPI:1831123264
Name:MCRAE, R PARKER (MD)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:PARKER
Last Name:MCRAE
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 1:5405 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5016
Mailing Address - Country:US
Mailing Address - Phone:309-691-4410
Mailing Address - Fax:
Practice Address - Street 1:5405 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5016
Practice Address - Country:US
Practice Address - Phone:309-691-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058843207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058843Medicaid
ILL29227Medicare PIN
ILC44297Medicare UPIN