Basic Information
| Provider Information | |||||||||
| NPI: | 1922085505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNEILL | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 532 S YORK ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601263952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308343668 | ||||||||
| FaxNumber: | 6308344015 | ||||||||
| Practice Location | |||||||||
| Address1: | 532 S YORK ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601263952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308343668 | ||||||||
| FaxNumber: | 6308344015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 07/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016005059 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 2230194 | 01 | IL | BC | OTHER | P00067255 | 01 | RR/MEDICARE | OTHER | 016005059 | 05 | IL | MEDICAID | 201857850 | 01 | IL | TAX ID | OTHER |