Unknown Individual – Vascular Surgery Physician, NPI 1912970617

Vascular Surgery Physician

Unknown Individual is a healthcare provider. based in Peoria, Illinois. specializing in Vascular Surgery Physician. They hold a License No. 036060685 (IL). The NPI Number for Unknown Individual is 1912970617

Main info

Organization

Inactive

55 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1912970617

Phone

(309) 674-2002

Address

515 NE GLEN OAK

Deactivation Date

23 August 2021

Doctor Profile

Medical School Name

BAYLOR COLLEGE OF MEDICINE

Secondary Phone

7015307000

Graduation Year

1971 (55 years ago)

PAC ID

2365330370

Group Practice PAC ID

8426960865

Professional Enrollment ID

I20191212002325

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience19

Completeness75

Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

Peoria Heights Grade School, 500, East Glen Avenue, Peoria Heights, Peoria County, Illinois, 61616, United States
SUITE 105
PEORIA, IL 616033167
Phone: (309) 674-2002
Fax: (309) 624-9898
Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 61603)

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Provider's Procedures

Unknown Individual performs procedures in Vascular Surgery Physician. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
THORACIC SURGERY	IL	33405	Replacement of left lower heart chamber valve using artificial valve on heart-lung machine	31	31

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 8426960865View full group profile

Name	Specialty	State
DR. LING SING CHOW (M.D.)	Internal Medicine	ND
KYLE WILEBSKI (M.D.)	A N E S T H E S I O L O G Y	IN
NICHOLAS C MAHR (MD)	-	ND
WAQAS KAYANI (MD)	H O S P I T A L I S T	ND
RENEE CHRIST (CRNA)	Certified Registered Nurse Anesthetist (Crna)	ND
DR. SUPRIYA KHAN (MD)	N E P H R O L O G Y	KY
DONNA M GALLIK (MD)	Cardiovascular Disease (Cardiology), Cardiac Electrophysiology	RI
DR. GEORGE FREDERICK ELLIS (MD)	-	NY
KIM E GEIGER (CRNA)	-	ND
DR. THEODROS SOLOMON (M.D., PH.D.)	Internal Medicine, Hospitalist	NC

Reviews

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Frequently asked questions

What is the 10-digit NPI for Unknown Individual?

Unknown Individual — NPI 1912970617 — is the standard way to identify this listing.

Why is Unknown Individual marked inactive in the NPI directory?

The public NPI listing for Unknown Individual is not currently active; confirm directly with the practice or licensing boards.

What taxonomy line describes Unknown Individual?

For research purposes, treat Unknown Individual as Vascular Surgery Physician in this dataset. Clinical services aligned with this taxonomy classification.

What address line appears for Unknown Individual?

Unknown Individual's geographic hint is Peoria, Illinois in our summary view.

Is the information about Unknown Individual up to date?

Data updates when providers file changes in NPPES — treat critical facts as "verify if unsure."