Provider Demographics
NPI:1902864796
Name:DEBORD, ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:DEBORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-655-2045
Mailing Address - Fax:309-655-3057
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-655-2045
Practice Address - Fax:309-655-3057
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP PTAN
ILCA4079OtherRR MEDICARE GROUP PTAN
ILP00651196OtherRR MEDICARE MEMBER PTAN
IL036055826Medicaid
ILR02868Medicare PIN
ILCA4079OtherRR MEDICARE GROUP PTAN