Provider Demographics
NPI:1750506846
Name:ILLINOIS VALLEY PODIATRY GROUP PC
Entity Type:Organization
Organization Name:ILLINOIS VALLEY PODIATRY GROUP PC
Other - Org Name:ILLINOIS VALLEY PODIATRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:BRATTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-691-5800
Mailing Address - Street 1:3322 W WILLOW KNOLLS
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-5800
Mailing Address - Fax:309-691-1336
Practice Address - Street 1:3322 W WILLOW KNOLLS
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-691-5800
Practice Address - Fax:309-691-1336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X, 213ES0103X, 213ES0131X
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007215174OtherBLUE CROSS BLUE SHIELD
ILCM5560OtherRAILROAD MEDICARE
IL0007215174OtherBLUE CROSS BLUE SHIELD
928270Medicare UPIN
IL0007215174OtherBLUE CROSS BLUE SHIELD