Peoria Obstetrics & Gynecology, S.C.

Primary specialty

Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X

License

036084069 Issued in IL

Legal business name

PEORIA OBSTETRICS & GYNECOLOGY, S.C.

Practice address

900 Main St Ste 660
Peoria, IL 61602-1060

Phone

(309) 687-4230

Fax

(309) 272-7704

NPI assigned

Mar 28, 2007

Last updated

Jan 26, 2009By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Paula M Clark

Title

Practice Administrator

Phone

(309) 687-4242

Specialties & licenses 1

Addresses

Other identifiers 7

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175040000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1232928000000",
    "number": "1477672020",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "900 MAIN ST STE 660",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616021060",
            "telephone_number": "309-687-4230",
            "fax_number": "309-272-7704"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 MAIN ST STE 660",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616021060",
            "telephone_number": "309-687-4230",
            "fax_number": "309-272-7704"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEORIA OBSTETRICS & GYNECOLOGY, S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-28",
        "last_updated": "2009-01-26",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "PAULA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "309-687-4242",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": "IL",
            "license": "036084069",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036065639",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036108543",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036084069",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036098292",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036111906",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036044919",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036062138",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Obstetrics & Gynecology Physician in Peoria, IL
• Providers in Peoria, IL by specialty
• Obstetrics & Gynecology Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.