Basic Information
| Provider Information | |||||||||
| NPI: | 1972612836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHUMWAY | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | NANNETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURGENER | ||||||||
| OtherFirstName: | TERRI | ||||||||
| OtherMiddleName: | NANNETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8600 N. ROUTE 91 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616150001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096835050 | ||||||||
| FaxNumber: | 3096835335 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 N. ROUTE 91 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616151111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096835050 | ||||||||
| FaxNumber: | 3096835335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-004693 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | DE5770 | 01 | IL | RR GROUP # | OTHER | TAX ID | 01 | IL | 30-0024900 | OTHER | 1972612836 | 01 | IL | NPI | OTHER | P00332136 | 01 | IL | RR MEDICARE INDIVIDUAL PI | OTHER | 0005832068 | 01 | IL | BCBS GROUP ID | OTHER | 1528084266 | 01 | IL | GROUP NPI | OTHER | 213056 | 01 | IL | MEDICARE GROUP | OTHER |