Provider Demographics
NPI:1376864959
Name:OLIVER-PAYNE, ROXIE N (MD)
Entity Type:Individual
Prefix:MRS
First Name:ROXIE
Middle Name:N
Last Name:OLIVER-PAYNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ROXIE
Other - Middle Name:N
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2214 U UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-680-7634
Mailing Address - Fax:309-676-5506
Practice Address - Street 1:711 W JOHN GWYNN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-671-2188
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-135116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036135116Medicaid