Provider Demographics
NPI:1184731663
Name:MIDWEST PODIATRY GROUP, PC
Entity type:Organization
Organization Name:MIDWEST PODIATRY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:SHELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-686-1000
Mailing Address - Street 1:3827 N PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61616-7767
Mailing Address - Country:US
Mailing Address - Phone:309-686-1000
Mailing Address - Fax:
Practice Address - Street 1:3827 N PROSPECT RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61616-7767
Practice Address - Country:US
Practice Address - Phone:309-686-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003172213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003172Medicaid
ILDA0891OtherRAILROAD MEDICARE
IL205059Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
ILDA0891OtherRAILROAD MEDICARE