Provider Demographics
NPI:1144425174
Name:TANCK, ALLISON RAE (MD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:RAE
Last Name:TANCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2017
Mailing Address - Country:US
Mailing Address - Phone:309-691-4005
Mailing Address - Fax:309-691-6144
Practice Address - Street 1:7303 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2017
Practice Address - Country:US
Practice Address - Phone:309-691-4005
Practice Address - Fax:309-691-6144
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL114425174OtherNPI