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General NPI Number Information
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NPI Number | 1952380628
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Entity Type | Organization
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Legal Business Name | PEORIA EAR NOSE AND THROAT GROUP SC
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Dates
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Enumeration Date | 01/11/2006
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 7301 N KNOXVILLE AVE
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City | PEORIA
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State | IL
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Zip | 61614-2017
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Country | US
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Telephone | 309-589-5900
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Fax | 309-689-0312
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Provider Business Mailing Address
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Address Line | 7301 N KNOXVILLE AVE
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City | PEORIA
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State | IL
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Zip | 61614-2017
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Country | US
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Telephone | 309-589-5900
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Fax | 309-683-4120
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Authorized Official
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Title or Position | CEO
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Name | TYLER ROBERTSON
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Credential |
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Telephone | 309-202-0462
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 042000742
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License Number State | IL
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