Provider Demographics
NPI:1194712547
Name:ALLERGY & ASTHMA OF ILLINOIS SC
Entity type:Organization
Organization Name:ALLERGY & ASTHMA OF ILLINOIS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-691-5200
Mailing Address - Street 1:6615 N BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2450
Mailing Address - Country:US
Mailing Address - Phone:309-691-5200
Mailing Address - Fax:309-691-5201
Practice Address - Street 1:6615 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2450
Practice Address - Country:US
Practice Address - Phone:309-691-5200
Practice Address - Fax:309-691-5201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042008003207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty