Provider Demographics
NPI:1104923499
Name:PEORIA SPECIALTY, INC.
Entity type:Organization
Organization Name:PEORIA SPECIALTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-693-4459
Mailing Address - Street 1:610 ABINGTON ST STE I
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3577
Mailing Address - Country:US
Mailing Address - Phone:309-693-4459
Mailing Address - Fax:309-693-5801
Practice Address - Street 1:610 ABINGTON ST STE I
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3577
Practice Address - Country:US
Practice Address - Phone:309-693-4459
Practice Address - Fax:309-693-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000663332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid