Basic Information
| Provider Information | |||||||||
| NPI: | 1609867373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKE | ||||||||
| FirstName: | STEVEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2505 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387783 | ||||||||
| FaxNumber: | 8122384506 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624411010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178262361 | ||||||||
| FaxNumber: | 2178262366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01029370 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036056646 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00312208 | 01 | IL | RR MEDICARE | OTHER | 200298970 | 05 | IN | MEDICAID | 036056646 | 05 | IL | MEDICAID |