Healthcare Provider Details

I. General information

NPI: 1821298555
Provider Name (Legal Business Name): CHARALAMBOS KYRIAKOS RAMMOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 N EXECUTIVE DR STE 100
PEORIA IL
61614-4896
US

IV. Provider business mailing address

4911 N EXECUTIVE DR STE 100
PEORIA IL
61614-4896
US

V. Phone/Fax

Practice location:
  • Phone: 309-670-0951
  • Fax: 309-670-0733
Mailing address:
  • Phone: 309-670-0951
  • Fax: 309-670-0733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125053834
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36.129302
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number106177
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number55759
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: