Organization
PEORIA TAZEWELL PATHOLOGY GROUP, S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RONALD CHAMPAGNE M.D. (PRESIDENT)
(309) 647-5240
Entity
Organization
Contact information
Practice address
221 NE GLEN OAK AVE, PEORIA, IL 61603-4310
(309) 672-4911
Mailing address
PO BOX 60070, N CHARLESTON, SC 29419-0070
(866) 759-4528
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
07215062
BLUE CROSS BLUE SHIELD
IL
01
—
CL6682
RAILROAD MEDICARE
IL
Enumeration date
07/11/2006
Last updated
08/13/2012
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