1033649967 NPI number — JULIA RACKLEY PERRY MEMORIAL HOSPITAL

Table of content: (NPI 1033649967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033649967 NPI number — JULIA RACKLEY PERRY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JULIA RACKLEY PERRY MEMORIAL HOSPITAL
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:
1033649967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 PARK AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61356-3901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-876-4419
Provider Business Mailing Address Fax Number:
815-876-4455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N MAIN ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61376-9707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-379-2020
Provider Business Practice Location Address Fax Number:
815-379-2018
Provider Enumeration Date:
06/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WELTE
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL STAFF SERVICES COORDINATOR
Authorized Official Telephone Number:
815-876-2293

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  0001883 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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