Provider Demographics
NPI:1649765835
Name:ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Entity Type:Organization
Organization Name:ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Other - Org Name:PEORIA ANESTHESIA SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-672-4980
Mailing Address - Street 1:1001 MAIN ST STE 500A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2038
Mailing Address - Country:US
Mailing Address - Phone:309-495-1121
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST STE 500A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2038
Practice Address - Country:US
Practice Address - Phone:309-495-1121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-29
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty