NPIMap

Organization Active NPI

Peoria Ear Nose and Throat Group SC

  • Otolaryngology Physician
  • Peoria, IL
National Provider Identifier
1952380628
Registry record updated Jul 22, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Otolaryngology PhysicianTaxonomy code 207Y00000X
License
042000742 Issued in IL
Legal business name
PEORIA EAR NOSE AND THROAT GROUP SC
Practice address
7301 N Knoxville Ave
Peoria, IL 61614-2017
Phone
(309) 589-5900
Fax
(309) 689-0312
NPI assigned
Jan 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 22, 2025

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

Authorized official

Name
Tyler Robertson
Title
Ceo
Phone
(309) 202-0462

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X 042000742 IL Primary

Addresses

Primary practice location

7301 N Knoxville Ave
Peoria, IL 61614-2017

Mailing address

7301 N Knoxville Ave
Peoria, IL 61614-2017
Phone (309) 589-5900

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050503001234 IL Part B Supplier - Clinic/Group Practice 9234179870 Receives reassigned benefits from 18 practitioners
Practice locations: Peoria, IL

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

6809 N Knoxville Ave
Peoria, IL 61614
Phone (309) 589-5900

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1136937600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1753142400000",
    "number": "1952380628",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7301 N KNOXVILLE AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616142017",
            "telephone_number": "309-589-5900",
            "fax_number": "309-683-4120"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7301 N KNOXVILLE AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616142017",
            "telephone_number": "309-589-5900",
            "fax_number": "309-689-0312"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEORIA EAR NOSE AND THROAT GROUP SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-11",
        "last_updated": "2025-07-22",
        "certification_date": "2025-07-22",
        "status": "A",
        "authorized_official_last_name": "ROBERTSON",
        "authorized_official_first_name": "TYLER",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "309-202-0462"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": "IL",
            "license": "042000742",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Peoria, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.