Basic Information
| Provider Information | |||||||||
| NPI: | 1275542045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEORIA SURGICAL GROUP, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 MAIN STREET | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616062037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094950200 | ||||||||
| FaxNumber: | 3096766545 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MAIN STREET | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616062037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094950200 | ||||||||
| FaxNumber: | 3096766545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROSSI | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | M.D./VICE PRESIDENT, MANAGING PART | ||||||||
| AuthorizedOfficialTelephone: | 3094950200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.