Provider Demographics
NPI:1154361921
Name:DAVID G VERMILLION M D P C
Entity type:Organization
Organization Name:DAVID G VERMILLION M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER/CODER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-942-5200
Mailing Address - Street 1:1802 N DIVISION ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1183
Mailing Address - Country:US
Mailing Address - Phone:815-513-5625
Mailing Address - Fax:815-513-5624
Practice Address - Street 1:1802 N DIVISION ST STE 201
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1183
Practice Address - Country:US
Practice Address - Phone:815-513-5625
Practice Address - Fax:815-513-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X207R00000X
IL208000000X208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0003221864OtherBLUE CROSS BLUE SHIELD
IL036082906Medicaid
IL019038OtherHEALTH ALLIANCE
IL370009963OtherRAIL ROAD MEDICARE
IL036082906Medicaid
IL212743Medicare ID - Type Unspecified