Provider Demographics
NPI:1275542045
Name:PEORIA SURGICAL GROUP, LTD.
Entity Type:Organization
Organization Name:PEORIA SURGICAL GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./VICE PRESIDENT, MANAGING PART
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-495-0200
Mailing Address - Street 1:1001 MAIN STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2037
Mailing Address - Country:US
Mailing Address - Phone:309-495-0200
Mailing Address - Fax:309-676-6545
Practice Address - Street 1:1001 MAIN STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2037
Practice Address - Country:US
Practice Address - Phone:309-495-0200
Practice Address - Fax:309-676-6545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty