1720223837 NPI number — PROCTOR HEALTH SYSTEMS

Table of content: (NPI 1720223837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720223837 NPI number — PROCTOR HEALTH SYSTEMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROCTOR HEALTH SYSTEMS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROCTOR MEDICAL GROUP SURGERY - C K SONG MD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720223837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 N KNOXVILLE AVE
Provider Second Line Business Mailing Address:
STE 209
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-5098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-691-1092
Provider Business Mailing Address Fax Number:
309-689-6092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 N KNOXVILLE AVE
Provider Second Line Business Practice Location Address:
STE 217
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-5098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-691-1092
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRINKER
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
Authorized Official Title or Position:
SYSTEM ANALYST
Authorized Official Telephone Number:
390-689-6089

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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