Healthcare Provider Details

I. General information

NPI: 1255853792
Provider Name (Legal Business Name): VISHAL KUMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2017
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 STATE ROUTE 91 STE 330
PEORIA IL
61615-7835
US

IV. Provider business mailing address

8600 STATE ROUTE 91 STE 330
PEORIA IL
61615-7835
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-4005
  • Fax:
Mailing address:
  • Phone: 309-691-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036167108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: