Healthcare Provider Details

I. General information

NPI: 1275542045
Provider Name (Legal Business Name): PEORIA SURGICAL GROUP, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN STREET SUITE 300
PEORIA IL
61606-2037
US

IV. Provider business mailing address

1001 MAIN STREET SUITE 300
PEORIA IL
61606-2037
US

V. Phone/Fax

Practice location:
  • Phone: 309-495-0200
  • Fax: 309-676-6545
Mailing address:
  • Phone: 309-495-0200
  • Fax: 309-676-6545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS ROSSI
Title or Position: M.D./VICE PRESIDENT, MANAGING PART
Credential: M.D.
Phone: 309-495-0200