Provider Demographics
NPI:1851582928
Name:ILLINOIS VALLEY PRIMARY CARE, LTD
Entity Type:Organization
Organization Name:ILLINOIS VALLEY PRIMARY CARE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIESNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-434-4900
Mailing Address - Street 1:1209 STARFIRE DR
Mailing Address - Street 2:#4
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1614
Mailing Address - Country:US
Mailing Address - Phone:815-434-4900
Mailing Address - Fax:815-434-2765
Practice Address - Street 1:1209 STARFIRE DR
Practice Address - Street 2:#4
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1614
Practice Address - Country:US
Practice Address - Phone:815-434-4900
Practice Address - Fax:815-434-2765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06848Medicare PIN