Provider Demographics
NPI:1336150283
Name:JD NIMRICK PC
Entity Type:Organization
Organization Name:JD NIMRICK PC
Other - Org Name:PREMIER HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-683-4646
Mailing Address - Street 1:PO BOX 3477
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-3477
Mailing Address - Country:US
Mailing Address - Phone:309-683-6900
Mailing Address - Fax:309-683-6902
Practice Address - Street 1:3531 W WILLOW KNOLLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1078
Practice Address - Country:US
Practice Address - Phone:309-683-6900
Practice Address - Fax:309-683-6902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206726Medicare ID - Type Unspecified