Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 036098051 | IL |
NPI | 1457389272 |
---|---|
Provider Name | Dr. Richard Pearl |
First Address | Peoria, IL 61603-3105 |
Second Address | Peoria, IL 61603-3105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036098051-2 | (05) | IL |
7215166 | BCBS (01) | IL |
G80841 | (02) | IL |