Provider Demographics
NPI:1568591048
Name:PERU PRIMARY CARE PROFESSIONALS LLC
Entity Type:Organization
Organization Name:PERU PRIMARY CARE PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-223-9214
Mailing Address - Street 1:920 WEST ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2763
Mailing Address - Country:US
Mailing Address - Phone:815-223-9214
Mailing Address - Fax:815-223-9322
Practice Address - Street 1:920 WEST ST
Practice Address - Street 2:SUITE 311
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2763
Practice Address - Country:US
Practice Address - Phone:815-223-9214
Practice Address - Fax:815-223-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111100207Q00000X
IL036089936207R00000X, 207RG0300X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111100Medicaid
IL036089936Medicaid
H75096Medicare UPIN
IL036111100Medicaid
IL036089936Medicaid
C52077Medicare UPIN
K08696Medicare ID - Type Unspecified