Healthcare Provider Details

I. General information

NPI: 1124138003
Provider Name (Legal Business Name): TAZEWELL PHYSICAL MEDICINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E WASHINGTON ST
EAST PEORIA IL
61611-2786
US

IV. Provider business mailing address

1100 E WASHINGTON ST
EAST PEORIA IL
61611-2786
US

V. Phone/Fax

Practice location:
  • Phone: 309-698-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-010333
License Number StateIL

VIII. Authorized Official

Name: DR. WILLIAM GREGORY WEINMAN
Title or Position: TREASURER
Credential: D.C.
Phone: 309-369-0434