Healthcare Provider Details

I. General information

NPI: 1396731063
Provider Name (Legal Business Name): MICHAEL D TARANTINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 07/30/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W NORTHMOOR RD
PEORIA IL
61614-3542
US

IV. Provider business mailing address

427 W NORTHMOOR RD
PEORIA IL
61614-3542
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-5337
  • Fax: 309-693-3913
Mailing address:
  • Phone: 309-692-5337
  • Fax: 309-693-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number29978
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number036-101239
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: