Provider Demographics
NPI:1477672020
Name:PEORIA OBSTETRICS & GYNECOLOGY, S.C.
Entity Type:Organization
Organization Name:PEORIA OBSTETRICS & GYNECOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-687-4242
Mailing Address - Street 1:900 MAIN ST STE 660
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1060
Mailing Address - Country:US
Mailing Address - Phone:309-687-4230
Mailing Address - Fax:309-272-7704
Practice Address - Street 1:900 MAIN ST STE 660
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1060
Practice Address - Country:US
Practice Address - Phone:309-687-4230
Practice Address - Fax:309-272-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084069207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065639Medicaid
IL036108543Medicaid
IL036084069Medicaid
IL036098292Medicaid
IL036111906Medicaid
IL036044919Medicaid
IL036062138Medicaid