Provider Demographics
NPI:1912097205
Name:SHEKLETON, MICHAEL F
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:SHEKLETON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-624-9400
Mailing Address - Fax:309-624-2280
Practice Address - Street 1:2805 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-624-9400
Practice Address - Fax:309-624-2280
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-062205207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062205Medicaid
ILK21762Medicare ID - Type UnspecifiedINDIVIDUAL #
IL036062205Medicaid
ILC44053Medicare UPIN
IL809840Medicare ID - Type UnspecifiedGROUP #
ILP00250105Medicare ID - Type UnspecifiedRR INDIVIDUAL #