Provider Demographics
NPI:1245544543
Name:PHILLIP A. IMMESOETE MD, LTD
Entity type:Organization
Organization Name:PHILLIP A. IMMESOETE MD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:IMMESOETE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-691-0030
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-691-0030
Mailing Address - Fax:309-691-9262
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-691-0030
Practice Address - Fax:309-691-9262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042568313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042568Medicaid
IL036042568Medicaid