Organization
PHILLIP A. IMMESOETE MD, LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PHILLIP ARTHUR IMMESOETE M.D. (PHYSICIAN)
(309) 691-0030
Entity
Organization
Contact information
Practice address
5401 N KNOXVILLE AVE, SUITE 406, PEORIA, IL 61614-5098
(309) 691-0030
(309) 691-9262
Mailing address
5401 N KNOXVILLE AVE, SUITE 406, PEORIA, IL 61614-5098
(309) 691-0030
(309) 691-9262
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
Primary
036042568
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036042568
—
IL
Enumeration date
07/29/2010
Last updated
07/29/2010
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