Provider Demographics
NPI:1578597738
Name:PEORIA TAZEWELL PATHOLOGY GROUP, S.C.
Entity Type:Organization
Organization Name:PEORIA TAZEWELL PATHOLOGY GROUP, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-647-5240
Mailing Address - Street 1:PO BOX 60070
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0070
Mailing Address - Country:US
Mailing Address - Phone:866-759-4528
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-4310
Practice Address - Country:US
Practice Address - Phone:309-672-4911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCL6682OtherRAILROAD MEDICARE
IL07215062OtherBLUE CROSS BLUE SHIELD
IL621294Medicare ID - Type Unspecified
ILCL6682OtherRAILROAD MEDICARE
IL621293Medicare ID - Type Unspecified
IL621292Medicare ID - Type Unspecified