Provider Demographics
NPI:1699839985
Name:PEORIA INTEGRATIVE MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:PEORIA INTEGRATIVE MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YANG
Authorized Official - Middle Name:
Authorized Official - Last Name:XIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-636-7302
Mailing Address - Street 1:4930 N EXECUTIVE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4894
Mailing Address - Country:US
Mailing Address - Phone:309-683-6002
Mailing Address - Fax:309-683-6007
Practice Address - Street 1:4930 N EXECUTIVE DR
Practice Address - Street 2:SUITE B
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4894
Practice Address - Country:US
Practice Address - Phone:309-683-6002
Practice Address - Fax:309-683-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114042Medicaid
IL036114042Medicaid
IL214777Medicare PIN