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Organization
MED-PEDS ASSOCIATES,P.C.
Active
Organization
MED-PEDS ASSOCIATES,P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. STONEWALL MCCUISTON JR. M.D. (PRESIDENT)
(815) 933-0194
Entity
Organization
Contact information
Practice address
375 N WALL ST, STE P520, KANKAKEE, IL 60901-3483
(815) 933-0194
(815) 933-1444
Mailing address
375 N WALL ST, STE P520, KANKAKEE, IL 60901-3483
(815) 933-0194
(815) 933-1444
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
036074737
IL
208000000X
Pediatrics Physician
Primary
036074737
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036074737
—
IL
01
—
4623239
BLUE CROSS/BLUE SHIELD OF ILLINOIS
IL
Enumeration date
03/21/2007
Last updated
10/20/2010
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