Provider Demographics
NPI:1093854002
Name:MID ILLINI SURGICAL ASSOCIATES SC
Entity Type:Organization
Organization Name:MID ILLINI SURGICAL ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:TOTTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-672-5975
Mailing Address - Street 1:900 MAIN STREET
Mailing Address - Street 2:SUITE 530
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1074
Mailing Address - Country:US
Mailing Address - Phone:309-672-5975
Mailing Address - Fax:309-655-1678
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 530
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1074
Practice Address - Country:US
Practice Address - Phone:309-672-5975
Practice Address - Fax:309-655-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty