Marcus Ismedhi Mutidjo, APN

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

209016806 Issued in IL

Practice address

1701 W Garden St
Peoria, IL 61605

Phone

(309) 680-7600

Fax

(309) 680-7686

NPI assigned

Jun 3, 2014

Last updated

Jan 14, 2019By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1401753600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1547424000000",
    "number": "1063825446",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2214 N UNIVERSITY ST",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616043221",
            "telephone_number": "309-680-7669",
            "fax_number": "309-681-8443"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1701 W GARDEN ST",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "61605",
            "telephone_number": "309-680-7600",
            "fax_number": "309-680-7686"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MUTIDJO",
        "first_name": "MARCUS",
        "middle_name": "ISMEDHI",
        "credential": "APN",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-06-03",
        "last_updated": "2019-01-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "IL",
            "license": "209016806",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jovie Ann Murtha, PT
• Ziad Musaitif, DO
• Musculoskeletal Surgery Center, LLC (Great Plains, LLC)
• Musculoskeletal Surgical Center (Orthopedic Institute ASC)
• Neha Choudary Muthavarapu, MD
• Millicent Mutisya
• Myeasyaccesshealthcare, PLLC
• Beth A Myers, CST
• Clifford Earl Myers, M.D.
• Debra Myers, FNPC

• Family Nurse Practitioner in Peoria, IL
• Providers in Peoria, IL by specialty
• Family Nurse Practitioner in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 14, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.