Healthcare Provider Details

I. General information

NPI: 1134582521
Provider Name (Legal Business Name): JOHN AMBROSE MIHELCIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 N WISCONSIN AVE
PEORIA IL
61603-5613
US

IV. Provider business mailing address

2214 N UNIVERSITY ST
PEORIA IL
61604-3221
US

V. Phone/Fax

Practice location:
  • Phone: 309-680-7600
  • Fax:
Mailing address:
  • Phone: 309-680-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.153454
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: