Healthcare Provider Details

I. General information

NPI: 1194712547
Provider Name (Legal Business Name): ALLERGY & ASTHMA OF ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 N BIG HOLLOW RD
PEORIA IL
61615-2450
US

IV. Provider business mailing address

6615 N BIG HOLLOW RD
PEORIA IL
61615-2450
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-5200
  • Fax: 309-691-5201
Mailing address:
  • Phone: 309-691-5200
  • Fax: 309-691-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number042008003
License Number StateIL

VIII. Authorized Official

Name: DR. STEPHEN J SMART
Title or Position: PRESIDENT
Credential: MD
Phone: 309-691-5200