1033163761 NPI number — PROCTOR HEALTH SYSTEMS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033163761 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:
Provider Other Organization Name Type Code:
6
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:
1033163761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2007
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:
SUITE 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:
309-689-6049
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:
SUITE 103
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:
309-691-7800
Provider Business Practice Location Address Fax Number:
309-691-7899
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHIARAVALLE
Authorized Official First Name:
CARRIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
309-689-6049

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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