Basic Information
| Provider Information | |||||||||
| NPI: | 1861433070 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERIK K. KOOBA, M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 SW MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096718749 | ||||||||
| FaxNumber: | 3096718740 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615544936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093471151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOOBA | ||||||||
| AuthorizedOfficialFirstName: | ERIK | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3096718749 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.