Healthcare Provider Details

I. General information

NPI: 1750506846
Provider Name (Legal Business Name): ILLINOIS VALLEY PODIATRY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 W WILLOW KNOLLS
PEORIA IL
61614
US

IV. Provider business mailing address

3322 W WILLOW KNOLLS
PEORIA IL
61614
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-5800
  • Fax: 309-691-1336
Mailing address:
  • Phone: 309-691-5800
  • Fax: 309-691-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: THOMAS KEVIN BRATTAIN
Title or Position: PODIATRIST
Credential: DPM
Phone: 309-691-5800