Provider Demographics
NPI:1598974651
Name:ILLINIOS VALLEY ORAL SURGEONS, P.C.
Entity type:Organization
Organization Name:ILLINIOS VALLEY ORAL SURGEONS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-224-1534
Mailing Address - Street 1:2050 MARQUETTE RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1597
Mailing Address - Country:US
Mailing Address - Phone:815-224-1534
Mailing Address - Fax:815-224-3018
Practice Address - Street 1:2050 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1597
Practice Address - Country:US
Practice Address - Phone:815-224-1534
Practice Address - Fax:815-224-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL773400Medicare ID - Type UnspecifiedPERU
IL773401Medicare ID - Type UnspecifiedOTTAWA