Provider Demographics
NPI:1083989578
Name:ILLINOIS WOMEN'S HEALTH CENTER
Entity Type:Organization
Organization Name:ILLINOIS WOMEN'S HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SUPERVISING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-683-0200
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-683-0200
Mailing Address - Fax:309-683-0201
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-683-0200
Practice Address - Fax:309-683-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001128207VG0400X
IL036083144207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty