Healthcare Provider Details

I. General information

NPI: 1558346544
Provider Name (Legal Business Name): FREDDY A ESCORCIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 HEATHERVIEW DR
EAST PEORIA IL
61611-4890
US

IV. Provider business mailing address

117 HEATHERVIEW DR
EAST PEORIA IL
61611-4890
US

V. Phone/Fax

Practice location:
  • Phone: 309-387-2733
  • Fax: 309-387-2733
Mailing address:
  • Phone: 309-387-2733
  • Fax: 309-387-2733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036092303
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: