Healthcare Provider Details

I. General information

NPI: 1699783886
Provider Name (Legal Business Name): JAMES R DEBORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 N KNOXVILLE AVE
PEORIA IL
61614-5016
US

IV. Provider business mailing address

PO BOX 10140
PEORIA IL
61612-0140
US

V. Phone/Fax

Practice location:
  • Phone: 877-852-4669
  • Fax:
Mailing address:
  • Phone: 877-852-4669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES DEBORD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 877-852-4669