Basic Information
| Provider Information | |||||||||
| NPI: | 1003452160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDANIEL | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 EXECUTIVE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605596137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303236116 | ||||||||
| FaxNumber: | 6307948620 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 W OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303236116 | ||||||||
| FaxNumber: | 6307948620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2019 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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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 | 363A00000X | PENDING | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | IL | ILLINOIS PA LICENSE | OTHER |