Healthcare Provider Details

I. General information

NPI: 1215066113
Provider Name (Legal Business Name): NICK A VLACHOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 SMOKEY CT
BLOOMINGTON IL
61704-2706
US

IV. Provider business mailing address

PEKIN HOSPITAL 600 S. 13TH STREET, SUITE K
PEKIN IL
61554-1109
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-1000
  • Fax: 309-661-1001
Mailing address:
  • Phone: 309-661-1000
  • Fax: 309-661-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: