Provider Demographics
NPI:1831143585
Name:PEORIA PULMONARY ASSOCIATES, LTD.
Entity type:Organization
Organization Name:PEORIA PULMONARY ASSOCIATES, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-672-5682
Mailing Address - Street 1:1001 MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1907
Mailing Address - Country:US
Mailing Address - Phone:309-672-5682
Mailing Address - Fax:309-672-3147
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1907
Practice Address - Country:US
Practice Address - Phone:309-672-5682
Practice Address - Fax:309-672-3147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7215056OtherBCBS GROUP NUMBER
IL614912Medicare ID - Type UnspecifiedGROUP NUMBER