1588813133 NPI number — PEORIA PODIATRY GROUP PC

Table of content: (NPI 1588813133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588813133 NPI number — PEORIA PODIATRY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEORIA PODIATRY GROUP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588813133
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
614 SPRING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61603-4133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-637-2325
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
614 SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61603-4133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-637-2325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUFF
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-637-3668

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  016003701 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1366440166 . This is a "JOHN D RUFF DPM" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 016003701 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1598926289(INDNPI) . This is a "ASSOCIATE-RACHEL S GRIEDER, DPM" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1588813133 (GRP NPI) . This is a "ASSOCIATE--RACHEL S GRIEDER, DPM" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1588813133(GRP.NPI) . This is a "JOHN D RUFF DPM" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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