Provider Demographics
NPI:1376680363
Name:NEUROLOGY CLINIC OF PEORIA SC
Entity Type:Organization
Organization Name:NEUROLOGY CLINIC OF PEORIA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-692-9516
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 414
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-9516
Mailing Address - Fax:309-692-9530
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 414
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-9516
Practice Address - Fax:309-692-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617586261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088131Medicaid
ILG21033Medicare UPIN
IL036088131Medicaid
130024968Medicare PIN
IL208702Medicare PIN
4687020001Medicare NSC