Provider Demographics
NPI:1235144056
Name:JONGERIUS, NICOLAAS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:NICOLAAS
Middle Name:MICHAEL
Last Name:JONGERIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 UNIVERSITY AVENUE SUITE 107
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-740-4232
Mailing Address - Fax:
Practice Address - Street 1:5016 UNIVERSITY AVENUE SUITE 107
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-740-4232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL472311OtherHEALTHLINK
ILIL01P9OtherJOHN DEERE
IL0360689871Medicaid
IL080039157OtherRAILROAD MEDICARE
IL7215059OtherBCBS PPO
ILK00093Medicare PIN
IL0360689871Medicaid