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General NPI Number Information
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NPI Number | 1083848188
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Entity Type | Organization
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Legal Business Name | SUSAN J COLE, MD & ASSOCIATES
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Dates
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Enumeration Date | 05/05/2009
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Last Update Date | 05/05/2009
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Provider Practice Location Address
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Address Line | 5401 N KNOXVILLE AVE SUITE 107
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City | PEORIA
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State | IL
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Zip | 61614-5098
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Country | US
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Telephone | 309-691-2311
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Fax | 309-691-2320
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Provider Business Mailing Address
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Address Line | 5401 N KNOXVILLE AVE SUITE 107
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City | PEORIA
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State | IL
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Zip | 61614-5098
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Country | US
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Telephone | 309-691-2311
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Fax | 309-691-2320
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Authorized Official
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Title or Position | LEAD PHYSICIAN
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Name | DR. SUSAN JOAN COLE
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Credential | MD
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Telephone | 309-691-2311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 036062798
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License Number State | IL
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