Provider Demographics
NPI:1053656298
Name:MEREDITH, ALAN MICHAEL (PAC)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:MICHAEL
Last Name:MEREDITH
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-364-7586
Mailing Address - Fax:
Practice Address - Street 1:1551 N IL RT 3
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298
Practice Address - Country:US
Practice Address - Phone:618-504-5008
Practice Address - Fax:618-504-5009
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024018875363A00000X
IL085.004538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant