Healthcare Provider Details

I. General information

NPI: 1952380628
Provider Name (Legal Business Name): PEORIA EAR, NOSE AND THROAT GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

IV. Provider business mailing address

7301 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

V. Phone/Fax

Practice location:
  • Phone: 309-589-5900
  • Fax: 309-689-0312
Mailing address:
  • Phone: 309-589-5900
  • Fax: 309-689-0312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number042000742
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State

VIII. Authorized Official

Name: TYLER ROBERTSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 309-589-8051