Organization
UNIVERSITY OF ILLINOIS
Active
Other names
Medical Service Plan at Peoria
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM R NICHOLAS PHD (EXECUTIVE DIRECTOR OF MSP)
(312) 413-0573
Entity
Organization
Contact information
Practice address
515 NE GLEN OAK AVE, PEDIATRIC NEUROLOGY, PEORIA, IL 61603-3165
(309) 624-9844
Mailing address
1 ILLINI DR, PEORIA, IL 61605-2576
(309) 671-8503
Taxonomy
Speciality
Code
Description
License number
State
2080P0008X
Pediatric Neurodevelopmental Disabilities Physician
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
07215036
BCBS
IL
Enumeration date
02/09/2006
Last updated
08/22/2020
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