Healthcare Provider Details

I. General information

NPI: 1841447653
Provider Name (Legal Business Name): ILLINOIS NEUROLOGICAL INSTITUTE-PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PENNSYLVANIA AVE
PEORIA IL
61603-3089
US

IV. Provider business mailing address

200 E PENNSYLVANIA AVE
PEORIA IL
61603-3089
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-4000
  • Fax: 309-624-4010
Mailing address:
  • Phone: 309-624-4000
  • Fax: 309-624-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES M MOORE
Title or Position: CEO
Credential:
Phone: 309-655-2850