Provider Demographics
NPI:1720031602
Name:TEVERBAUGH CROLAND & MUELLER OB/GYN & ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:TEVERBAUGH CROLAND & MUELLER OB/GYN & ASSOCIATES, S.C.
Other - Org Name:COURI-TEVERBAUGH OB/GYN & ASSOC S.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:TEVERBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-692-2025
Mailing Address - Street 1:8600 N. RT 91
Mailing Address - Street 2:SUITE 330
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615
Mailing Address - Country:US
Mailing Address - Phone:309-692-2025
Mailing Address - Fax:309-692-2446
Practice Address - Street 1:8600 N. RT 91
Practice Address - Street 2:#330
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615
Practice Address - Country:US
Practice Address - Phone:309-692-2025
Practice Address - Fax:309-692-2446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102227174400000X
IL207V00000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07232044OtherBLUE CROSS BLUE SHIELD
209017Medicare PIN
IL209017Medicare PIN