Provider Demographics
NPI:1063985240
Name:MCKNIGHT, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MCKNIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2259 PELL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:62910-2306
Mailing Address - Country:US
Mailing Address - Phone:618-638-3717
Mailing Address - Fax:
Practice Address - Street 1:306 W 8TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1653
Practice Address - Country:US
Practice Address - Phone:618-524-3653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL104100000XMedicaid
ILPAUL2259Medicaid