Provider Demographics
NPI:1073501359
Name:KROCK, JEREMY L (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:L
Last Name:KROCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 N STATE ROUTE 91
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9541
Mailing Address - Country:US
Mailing Address - Phone:309-692-5393
Mailing Address - Fax:309-692-2538
Practice Address - Street 1:8600 N STATE ROUTE 91
Practice Address - Street 2:SUITE 250
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9541
Practice Address - Country:US
Practice Address - Phone:309-692-5393
Practice Address - Fax:309-692-2538
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093120207L00000X, 207LP2900X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL64984Medicare ID - Type Unspecified
A12837Medicare UPIN