Provider Demographics
NPI:1144313404
Name:PROEHL, TRENT D (MD)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:D
Last Name:PROEHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:IL
Mailing Address - Zip Code:61747-7525
Mailing Address - Country:US
Mailing Address - Phone:309-449-4338
Mailing Address - Fax:309-449-4880
Practice Address - Street 1:107 TREMONT ST
Practice Address - Street 2:
Practice Address - City:HOPEDALE
Practice Address - State:IL
Practice Address - Zip Code:61747-7525
Practice Address - Country:US
Practice Address - Phone:309-449-4338
Practice Address - Fax:309-449-4880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111370208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111370Medicaid
I10225Medicare UPIN
ILK07557Medicare ID - Type UnspecifiedINDIVIDUAL #
IL036111370Medicaid
ILP00339522Medicare ID - Type UnspecifiedRR INDIVIDUAL #