Provider Demographics
NPI:1972507747
Name:INTERNAL MEDICINE GROUP OF PEORIA SC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE GROUP OF PEORIA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-655-7888
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3045
Mailing Address - Country:US
Mailing Address - Phone:309-655-7888
Mailing Address - Fax:
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:STE 105
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3045
Practice Address - Country:US
Practice Address - Phone:309-655-7888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215840Medicare ID - Type Unspecified