Provider Demographics
NPI:1588813133
Name:PEORIA PODIATRY GROUP PC
Entity Type:Organization
Organization Name:PEORIA PODIATRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:RUFF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-637-3668
Mailing Address - Street 1:614 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-4133
Mailing Address - Country:US
Mailing Address - Phone:309-637-2325
Mailing Address - Fax:
Practice Address - Street 1:614 SPRING ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-4133
Practice Address - Country:US
Practice Address - Phone:309-637-2325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003701213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1366440166OtherJOHN D RUFF DPM
IL016003701Medicaid
IL1598926289(INDNPI)OtherASSOCIATE-RACHEL S GRIEDER, DPM
IL1588813133 (GRP NPI)OtherASSOCIATE--RACHEL S GRIEDER, DPM
IL1588813133(GRP.NPI)OtherJOHN D RUFF DPM
IL1588813133 (GRP NPI)OtherASSOCIATE--RACHEL S GRIEDER, DPM
ILT38405Medicare UPIN
IL1598926289(INDNPI)OtherASSOCIATE-RACHEL S GRIEDER, DPM