Healthcare Provider Details

I. General information

NPI: 1215273131
Provider Name (Legal Business Name): EDWARD W PEGG IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 08/28/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 EASTLAND DR
BLOOMINGTON IL
61704-3567
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-6900
  • Fax: 309-661-6990
Mailing address:
  • Phone: 217-383-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036141863
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: