Provider Demographics
NPI:1124138003
Name:TAZEWELL PHYSICAL MEDICINE SC
Entity type:Organization
Organization Name:TAZEWELL PHYSICAL MEDICINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:WEINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-369-0434
Mailing Address - Street 1:1100 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-2786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2786
Practice Address - Country:US
Practice Address - Phone:309-698-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010333111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214159Medicare ID - Type Unspecified