Provider Demographics
NPI:1215327101
Name:PLATINUM MEDICAL ASSOCIATES, LTD
Entity type:Organization
Organization Name:PLATINUM MEDICAL ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS TARA
Authorized Official - Middle Name:BULAON
Authorized Official - Last Name:DELOS REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-742-3941
Mailing Address - Street 1:2401 W ALTA RD
Mailing Address - Street 2:APT 3306
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6156
Practice Address - Country:US
Practice Address - Phone:773-742-3941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130229207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty