Healthcare Provider Details

I. General information

NPI: 1861433070
Provider Name (Legal Business Name): ERIK K. KOOBA, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 13TH ST
PEKIN IL
61554-4936
US

IV. Provider business mailing address

108 SW MADISON AVE
PEORIA IL
61602-1107
US

V. Phone/Fax

Practice location:
  • Phone: 309-347-1151
  • Fax:
Mailing address:
  • Phone: 309-671-8749
  • Fax: 309-671-8740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: ERIK K KOOBA
Title or Position: OWNER
Credential: M.D.
Phone: 309-671-8749