Provider Demographics
NPI:1639389661
Name:MATERNAL FETAL MEDICINE ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:MATERNAL FETAL MEDICINE ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARYTREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENFROE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-683-6704
Mailing Address - Street 1:PO BOX 3873
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-3873
Mailing Address - Country:US
Mailing Address - Phone:309-683-6704
Mailing Address - Fax:309-683-6722
Practice Address - Street 1:4911 N EXECUTIVE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4896
Practice Address - Country:US
Practice Address - Phone:309-683-6704
Practice Address - Fax:309-683-6722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL424220Medicare ID - Type Unspecified