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General NPI Number Information
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NPI Number | 1699839985
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Entity Type | Organization
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Legal Business Name | PEORIA INTEGRATIVE MEDICAL CENTER LTD
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 04/20/2009
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Provider Practice Location Address
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Address Line | 4930 N EXECUTIVE DR SUITE B
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City | PEORIA
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State | IL
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Zip | 61614-4894
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Country | US
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Telephone | 309-683-6002
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Fax | 309-683-6007
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Provider Business Mailing Address
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Address Line | 4930 N EXECUTIVE DR SUITE B
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City | PEORIA
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State | IL
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Zip | 61614-4894
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Country | US
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Telephone | 309-683-6002
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Fax | 309-683-6007
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Authorized Official
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Title or Position | OWNER
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Name | YANG XIE
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Credential | M.D.
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Telephone | 309-636-7302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036114042
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License Number State | IL
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