Healthcare Provider Details

I. General information

NPI: 1558358911
Provider Name (Legal Business Name): PENELOPE A EWBANK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 N BIG HOLLOW RD
PEORIA IL
61615
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-5200
  • Fax: 309-691-5201
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036104932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: