Provider Demographics
NPI:1841447653
Name:ILLINOIS NEUROLOGICAL INSTITUTE-PHYSICIANS LLC
Entity type:Organization
Organization Name:ILLINOIS NEUROLOGICAL INSTITUTE-PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-655-2850
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-624-4000
Mailing Address - Fax:309-624-4010
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-624-4000
Practice Address - Fax:309-624-4010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSF HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-22
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6181730001Medicare NSC
ILIL1048Medicare PIN