Healthcare Provider Details

I. General information

NPI: 1811016702
Provider Name (Legal Business Name): BOCHANTIN OBSTETRICS & GYNECOLOGY SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 308
PEORIA IL
61614-5098
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 308
PEORIA IL
61614-5098
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-5100
  • Fax: 309-692-1400
Mailing address:
  • Phone: 309-692-5100
  • Fax: 309-692-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036098292
License Number StateIL

VIII. Authorized Official

Name: MARLA TOMLINSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 309-692-5100