Provider Demographics
NPI:1225062573
Name:GINOLI, METYL A (NP)
Entity Type:Individual
Prefix:
First Name:METYL
Middle Name:A
Last Name:GINOLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:METYL
Other - Middle Name:A
Other - Last Name:RAVAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-655-2000
Mailing Address - Fax:309-655-7869
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-624-8500
Practice Address - Fax:309-624-8552
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
207414OtherMEDICARE GROUP NO.
P85562Medicare UPIN
K22151Medicare ID - Type Unspecified