Provider Demographics
NPI:1952379042
Name:DESROSIERS, PAUL M (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:DESROSIERS
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 1:1541 RIVERBOAT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-9341
Mailing Address - Country:US
Mailing Address - Phone:815-409-4957
Mailing Address - Fax:
Practice Address - Street 1:1541 RIVERBOAT CENTER DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-9341
Practice Address - Country:US
Practice Address - Phone:815-409-4957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047188A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200279370Medicaid
IN000000744259OtherANTHEM PROVIDER NUMBER
INH16126Medicare UPIN
IN200279370Medicaid
IN000000744259OtherANTHEM PROVIDER NUMBER
M400056817Medicare PIN
INP01090939Medicare PIN