MEDICARE: PEORIA EYE CLINIC, LTD

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	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	37103572	OTHER	IL	FEDERAL TAX ID NUMBER

General Provider Information

NPI Number	:	1366424756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEORIA EYE CLINIC, LTD

Provider Business Mailing Address
First Line	:	2422 W NEBRASKA AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-3112
Country	:	US
Telephone Number	:	309-676-2020
Fax Number	:	309-673-2020

Provider Business Practice Location Address
First Line	:	2422 W NEBRASKA AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-3112
Country	:	US
Telephone Number	:	309-676-2020
Fax Number	:	309-673-2020

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN C NELSON
Credential	:	MD
Telephone Number	:	309-676-2020

Provider Enumeration Date	:	11/19/2005
Last Update Date	:	08/22/2020

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Directions to “PEORIA EYE CLINIC, LTD ” Practice Location

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