Provider Demographics
NPI:1134118235
Name:TIBLANDI, MICHAEL D (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:TIBLANDI
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:2005-10-20
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088492207Q00000X, 207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088492Medicaid
IL036088492Medicaid
F81369Medicare UPIN