Provider Demographics
NPI:1255721502
Name:PEORIA HAND SURGERY, LLC
Entity type:Organization
Organization Name:PEORIA HAND SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ADAMSON
Authorized Official - Suffix:X
Authorized Official - Credentials:MD
Authorized Official - Phone:309-693-3970
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-693-3970
Mailing Address - Fax:309-693-3971
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-693-3970
Practice Address - Fax:309-693-3971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089935207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36089935Medicaid
IL36089935Medicaid
ILL34918Medicare PIN