Healthcare Provider Details

I. General information

NPI: 1083989578
Provider Name (Legal Business Name): ILLINOIS WOMEN'S HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 114
PEORIA IL
61614-5098
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 114
PEORIA IL
61614-5098
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-0200
  • Fax: 309-683-0201
Mailing address:
  • Phone: 309-683-0200
  • Fax: 309-683-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036083144
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number209001128
License Number StateIL

VIII. Authorized Official

Name: DR. LINDSEY A MA
Title or Position: OWNER/SUPERVISING PHYSICIAN
Credential: M.D.
Phone: 309-683-0200