MEDICARE: ILLINOIS VALLEY EAR, NOSE & THROAT ASSOCIATES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician
2	207YX0901X	Otology & Neurotology Physician
3	261QM2500X	Medical Specialty Clinic/Center	336-079161	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316163926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS VALLEY EAR, NOSE & THROAT ASSOCIATES, INC.

Provider Business Mailing Address
First Line	:	4231 PROGRESS BLVD STE 2
Second Line	:
City	:	PERU
State	:	IL
Zip	:	61354-1193
Country	:	US
Telephone Number	:	815-224-0082
Fax Number	:	815-224-1071

Provider Business Practice Location Address
First Line	:	4231 PROGRESS BLVD STE 2
Second Line	:
City	:	PERU
State	:	IL
Zip	:	61354-1193
Country	:	US
Telephone Number	:	815-224-0082
Fax Number	:	815-224-1071

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. BULENT MAMIKOGLU
Credential	:	M.D.
Telephone Number	:	815-224-0082

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	01/22/2020

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Directions to “ILLINOIS VALLEY EAR, NOSE & THROAT ASSOCIATES, INC. ” Practice Location

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