Provider Demographics
NPI:1043227846
Name:SEABOCH, RICHARD S (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:SEABOCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-4410
Mailing Address - Fax:309-589-2830
Practice Address - Street 1:5405 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-691-4410
Practice Address - Fax:309-589-2830
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001201363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001201Medicaid
IL085001201Medicaid
ILS29871Medicare UPIN