Basic Information
| Provider Information | |||||||||
| NPI: | 1770646515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSEPH | ||||||||
| FirstName: | M | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD FACC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOSEPH | ||||||||
| OtherFirstName: | MELETH | ||||||||
| OtherMiddleName: | THOMMY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3331 W DEYOUNG ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189987600 | ||||||||
| FaxNumber: | 6189976680 | ||||||||
| Practice Location | |||||||||
| Address1: | 3331 W DEYOUNG ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189987600 | ||||||||
| FaxNumber: | 6189973630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 09/20/2013 | ||||||||
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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 | 207RC0000X | 036045640 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 026849200 | 01 | FEDERAL BLACK LUNG | OTHER | 036045640 | 05 | IL | MEDICAID | 0010000066 | 01 | IL | BCBS OF IL | OTHER | K46805 | 01 | IL | INDIVIDUAL PTAN | OTHER |