Provider Demographics
NPI:1528205069
Name:ILLINOIS NEUROLOGICAL INSTITUTE-PHYSICIANS LLC
Entity Type:Organization
Organization Name:ILLINOIS NEUROLOGICAL INSTITUTE-PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-655-2850
Mailing Address - Street 1:719 N WILLIAM KUMPF BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:719 N WILLIAM KUMPF BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2530
Practice Address - Country:US
Practice Address - Phone:309-676-0766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSF HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-20
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicare Oscar/Certification