Healthcare Provider Details

I. General information

NPI: 1588813133
Provider Name (Legal Business Name): PEORIA PODIATRY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 SPRING ST
PEORIA IL
61603-4133
US

IV. Provider business mailing address

614 SPRING ST
PEORIA IL
61603-4133
US

V. Phone/Fax

Practice location:
  • Phone: 309-637-2325
  • Fax:
Mailing address:
  • Phone: 309-637-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016003701
License Number StateIL

VIII. Authorized Official

Name: JOHN DANIEL RUFF
Title or Position: PRESIDENT
Credential: DPM
Phone: 309-637-3668