Provider Demographics
NPI:1255482543
Name:SCHROCK, KEVIN J (O T)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:SCHROCK
Suffix:
Gender:M
Credentials:O T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2338 W SUD PKWY
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7483
Mailing Address - Country:US
Mailing Address - Phone:309-693-9189
Mailing Address - Fax:309-693-9946
Practice Address - Street 1:2338 W SUD PKWY
Practice Address - Street 2:STE 3100
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7483
Practice Address - Country:US
Practice Address - Phone:309-693-9189
Practice Address - Fax:309-693-9946
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005963225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01030410OtherRR MEDICARE
IL537460033Medicare PIN