Basic Information
| Provider Information | |||||||||
| NPI: | 1679633143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2905 N. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178779117 | ||||||||
| FaxNumber: | 2178773082 | ||||||||
| Practice Location | |||||||||
| Address1: | 2905 N. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | DECATURE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178779117 | ||||||||
| FaxNumber: | 2178773078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 06/27/2012 | ||||||||
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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 | 2006-0962 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0505X | 036.060478 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036.060478 | 05 | IL | MEDICAID |