Healthcare Provider Details

I. General information

NPI: 1851582928
Provider Name (Legal Business Name): ILLINOIS VALLEY PRIMARY CARE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 STARFIRE DR #4
OTTAWA IL
61350-1614
US

IV. Provider business mailing address

1209 STARFIRE DR #4
OTTAWA IL
61350-1614
US

V. Phone/Fax

Practice location:
  • Phone: 815-434-4900
  • Fax: 815-434-2765
Mailing address:
  • Phone: 815-434-4900
  • Fax: 815-434-2765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DAWN MIESNER
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 815-434-4900