Provider Demographics
NPI:1538498209
Name:DR. RICHARD D. CORLEY, S.C.
Entity Type:Organization
Organization Name:DR. RICHARD D. CORLEY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:CORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-674-2822
Mailing Address - Street 1:416 ST. MARK CT.
Mailing Address - Street 2:#106
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-1928
Mailing Address - Country:US
Mailing Address - Phone:309-674-2822
Mailing Address - Fax:309-674-4250
Practice Address - Street 1:416 ST. MARK CT.
Practice Address - Street 2:#106
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-1928
Practice Address - Country:US
Practice Address - Phone:309-674-2822
Practice Address - Fax:309-674-4250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-037-295208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036037295Medicaid
D10465Medicare UPIN
266890Medicare PIN