Healthcare Provider Details

I. General information

NPI: 1649765835
Provider Name (Legal Business Name): ILLINOIS GASTROENTEROLOGY INSTITUTE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST STE 500A
PEORIA IL
61606-2038
US

IV. Provider business mailing address

1001 MAIN ST STE 500A
PEORIA IL
61606-2038
US

V. Phone/Fax

Practice location:
  • Phone: 309-495-1121
  • Fax:
Mailing address:
  • Phone: 309-495-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: TERRY L BALDWIN
Title or Position: MD
Credential:
Phone: 309-672-4980