Provider Demographics
NPI:1891706503
Name:MACEREN, RAYMOND G (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:G
Last Name:MACEREN
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 1:105 S FIRST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-8973
Mailing Address - Country:US
Mailing Address - Phone:815-476-5210
Mailing Address - Fax:815-476-4193
Practice Address - Street 1:105 S FIRST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:IL
Practice Address - Zip Code:60481-8973
Practice Address - Country:US
Practice Address - Phone:815-476-5210
Practice Address - Fax:815-476-4193
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115249207Q00000X
IL036115249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115249Medicaid
IL36-3167726Medicare ID - Type UnspecifiedGROUP TAX ID#
ILK29829Medicare PIN
IL036115249Medicaid
IL356250Medicare ID - Type UnspecifiedMEDICARE GROUP #