Healthcare Provider Details

I. General information

NPI: 1720179773
Provider Name (Legal Business Name): PREM L BHATIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9118 N LINDBERGH DR
PEORIA IL
61615-1422
US

IV. Provider business mailing address

1120 E WAR MEMORIAL DR
PEORIA HEIGHTS IL
61616-7757
US

V. Phone/Fax

Practice location:
  • Phone: 309-693-3993
  • Fax: 309-693-8027
Mailing address:
  • Phone: 309-685-0100
  • Fax: 309-685-0172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036061636
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: