Healthcare Provider Details

I. General information

NPI: 1386081792
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF ILLINOIS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 NE GLEN OAK AVE STE 301
PEORIA IL
61603-3105
US

IV. Provider business mailing address

800 NE GLEN OAK AVE STE 301
PEORIA IL
61603-3255
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-3453
  • Fax:
Mailing address:
  • Phone: 309-655-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN D SCHOEPLEIN
Title or Position: CEO
Credential:
Phone: 309-655-2850