Provider Demographics
NPI:1356430664
Name:MEDICAL GROUP OF MACOMB, LLC
Entity type:Organization
Organization Name:MEDICAL GROUP OF MACOMB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:309-833-3536
Mailing Address - Street 1:PO BOX 556
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0556
Mailing Address - Country:US
Mailing Address - Phone:309-833-3536
Mailing Address - Fax:309-836-5729
Practice Address - Street 1:505 E GRANT ST STE 103
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3308
Practice Address - Country:US
Practice Address - Phone:309-833-3536
Practice Address - Fax:309-836-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110247080OtherRAILROAD MEDICARE
IL5532005OtherBLUE CROSS/BLUE SHIELD IL
ILDG6820OtherRAILROAD MEDICARE
IL036104354Medicaid
IL036111319Medicaid
IL067033OtherHEALTH ALLIANCE
IL095260OtherHEALTH ALLIANCE
IL036104354Medicaid
IL036111319Medicaid
IL067033OtherHEALTH ALLIANCE
IL095260OtherHEALTH ALLIANCE
IL5532005OtherBLUE CROSS/BLUE SHIELD IL