Healthcare Provider Details

I. General information

NPI: 1902107733
Provider Name (Legal Business Name): BOYD OBSTETRICS & GYNECOLOGY OF CENTRAL ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST STE 660
PEORIA IL
61602-1060
US

IV. Provider business mailing address

900 MAIN ST STE 660
PEORIA IL
61602-1060
US

V. Phone/Fax

Practice location:
  • Phone: 309-687-4230
  • Fax: 309-687-4235
Mailing address:
  • Phone: 309-687-4230
  • Fax: 309-687-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036084069
License Number StateIL

VIII. Authorized Official

Name: PAULA CLARK
Title or Position: ADMINISTRATOR
Credential:
Phone: 309-687-4242