Healthcare Provider Details

I. General information

NPI: 1245680651
Provider Name (Legal Business Name): THOMAS JOSEPH BOLLAERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 N ALLEN RD
PEORIA IL
61614-3294
US

IV. Provider business mailing address

6000 N ALLEN RD
PEORIA IL
61614-3294
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-1400
  • Fax:
Mailing address:
  • Phone: 309-691-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125069405
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036.154509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: