Basic Information
| Provider Information | |||||||||
| NPI: | 1225038532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAURER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | TED | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 N WILLIAM KUMPF BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616052507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096765546 | ||||||||
| FaxNumber: | 3096765045 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 N WILLIAM KUMPF BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616052507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096765546 | ||||||||
| FaxNumber: | 3096765045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 12/04/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | 36082960 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 36082960 | 05 | IL | MEDICAID |