Healthcare Provider Details

I. General information

NPI: 1649898784
Provider Name (Legal Business Name): PETER EGWOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 N MISSOURI AVE
PEORIA IL
61603-3105
US

IV. Provider business mailing address

10 CENTER DR BLDG 10
BETHESDA MD
20892-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-3800
  • Fax: 309-623-2330
Mailing address:
  • Phone: 202-412-1982
  • Fax: 240-541-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2020020069
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD210011536
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036180445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: