MEDICARE: MARYJO MALIEKEL MD

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	390200000X	Student in an Organized Health Care Education/Training Program	BP10078213	TX
2	207R00000X	Internal Medicine Physician	125.073603	IL
3	207RR0500X	Rheumatology Physician	036171952	IL

General Provider Information

NPI Number	:	1497215784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYJO MALIEKEL MD

Provider Business Mailing Address
First Line	:	1800 N KNOXVILLE AVE STE E
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61603-3005
Country	:	US
Telephone Number	:	309-308-0910
Fax Number	:	309-308-0919

Provider Business Practice Location Address
First Line	:	1800 N KNOXVILLE AVE STE E
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61603-3005
Country	:	US
Telephone Number	:	309-308-0910
Fax Number	:	309-308-0919

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2019
Last Update Date	:	05/05/2025

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Directions to “ MARYJO MALIEKEL MD” Practice Location

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