Provider Demographics
NPI:1881786622
Name:TAMARA OLT, S.C., INC
Entity type:Organization
Organization Name:TAMARA OLT, S.C., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-692-2805
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-2805
Mailing Address - Fax:309-692-1913
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-2805
Practice Address - Fax:309-692-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07232119OtherBCBS GROUP NUMBER
IL212638Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER