Provider Demographics
NPI:1063538312
Name:MED-PEDS ASSOCIATES,P.C.
Entity type:Organization
Organization Name:MED-PEDS ASSOCIATES,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STONEWALL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUISTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:815-933-0194
Mailing Address - Street 1:375 N WALL ST
Mailing Address - Street 2:STE P520
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3483
Mailing Address - Country:US
Mailing Address - Phone:815-933-0194
Mailing Address - Fax:815-933-1444
Practice Address - Street 1:375 N WALL ST
Practice Address - Street 2:STE P520
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3483
Practice Address - Country:US
Practice Address - Phone:815-933-0194
Practice Address - Fax:815-933-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074737207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074737Medicaid
IL4623239OtherBLUE CROSS/BLUE SHIELD OF ILLINOIS
IL036074737Medicaid
ILCH9254Medicare PIN
IL=========-60901-01Medicaid
IL4623239OtherBLUE CROSS/BLUE SHIELD OF ILLINOIS