Healthcare Provider Details

I. General information

NPI: 1215990189
Provider Name (Legal Business Name): MARCUS OHNEMUS A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W BRADLEY AVE
PEORIA IL
61625-0001
US

IV. Provider business mailing address

811 E GLEN AVE
PEORIA HEIGHTS IL
61616-5205
US

V. Phone/Fax

Practice location:
  • Phone: 309-677-3072
  • Fax:
Mailing address:
  • Phone: 309-256-3185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: