Provider Demographics
NPI:1659672129
Name:PEORIA OBSTETRICS & GYNECOLOGY OF CENTRAL ILLINOIS
Entity Type:Organization
Organization Name:PEORIA OBSTETRICS & GYNECOLOGY OF CENTRAL ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-687-4242
Mailing Address - Street 1:900 MAIN ST STE 660
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1060
Mailing Address - Country:US
Mailing Address - Phone:309-687-4230
Mailing Address - Fax:309-687-4235
Practice Address - Street 1:900 MAIN ST STE 660
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1060
Practice Address - Country:US
Practice Address - Phone:309-687-4230
Practice Address - Fax:309-687-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty