Provider Demographics
NPI:1972539575
Name:DETERS, PATRICIA A (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:DETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 W ALTORFER DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1807
Mailing Address - Country:US
Mailing Address - Phone:309-683-7700
Mailing Address - Fax:309-683-7752
Practice Address - Street 1:2265 W ALTORFER DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1807
Practice Address - Country:US
Practice Address - Phone:309-683-7700
Practice Address - Fax:309-683-7752
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095780207PE0004X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095780Medicaid
ILG64520Medicare UPIN
ILL70523Medicare PIN