Basic Information
| Provider Information | |||||||||
| NPI: | 1174747885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISCHLER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616370001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096248818 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616370001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096248818 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
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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 | 207R00000X | 4301081766 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 4301081766 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 4301081766 | MI | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | 4301081766 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 809840 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 036121322 | 05 | IL | MEDICAID | P00617104 | 01 | IL | RR MEDICARE GROUP MEMBER PTAN | OTHER | CA4079 | 01 | IL | RR MEDICARE GROUP PTAN | OTHER |