Healthcare Provider Details

I. General information

NPI: 1598831794
Provider Name (Legal Business Name): MIDWEST FAMILY MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 400
PEORIA IL
61614-5021
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 400
PEORIA IL
61614-5021
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-0909
  • Fax: 309-689-3434
Mailing address:
  • Phone: 309-689-0909
  • Fax: 309-689-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number036089054
License Number StateIL

VIII. Authorized Official

Name: MS. MARY J MCCUMBER
Title or Position: OFFICE MANAGER
Credential:
Phone: 309-689-0909