Healthcare Provider Details

I. General information

NPI: 1881786622
Provider Name (Legal Business Name): TAMARA OLT, S.C., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 109
PEORIA IL
61614-5098
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 109
PEORIA IL
61614-5098
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-2805
  • Fax: 309-692-1913
Mailing address:
  • Phone: 309-692-2805
  • Fax: 309-692-1913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. TAMARA OLT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 309-692-2805