Healthcare Provider Details

I. General information

NPI: 1902249154
Provider Name (Legal Business Name): NICOLE MARIE RAU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-0610
  • Fax: 309-655-2974
Mailing address:
  • Phone: 309-624-0610
  • Fax: 309-655-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036147994
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: