Individual
DR. STONEWALL MCCUISTON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
375 N WALL ST STE P310, KANKAKEE, IL 60901-3484
(815) 933-0194
(815) 936-3847
Mailing address
375 N WALL ST STE P310, KANKAKEE, IL 60901-3484
(815) 933-0194
(815) 936-3847
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 AND BLUE SHIELD OF ILLINOIS
IL
Enumeration date
08/31/2005
Last updated
03/29/2021
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