Healthcare Provider Details

I. General information

NPI: 1235389727
Provider Name (Legal Business Name): LINDSAY BRIANN TATE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 OLT AVE
PEKIN IL
61554-6214
US

IV. Provider business mailing address

347 SCHULZKI LN
EAST PEORIA IL
61611-9487
US

V. Phone/Fax

Practice location:
  • Phone: 309-353-6301
  • Fax: 407-648-3686
Mailing address:
  • Phone: 864-293-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036133748
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: