Individual
MIKE STAFF
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
2601 W MAIN ST, CARBONDALE, IL 62901-1031
(618) 549-5361
(618) 549-5128
Mailing address
PO BOX 1105, INDIANAPOLIS, IN 46206-1105
(618) 549-5361
(618) 549-5128
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085-000618
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
028748
HAMP
IL
01
—
3932056
BCBS OF IL
IL
01
—
7210895
AETNA
IL
Enumeration date
12/28/2006
Last updated
07/11/2011
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