1033862743 NPI number — GREATER PEORIA SPECIALTY HOSPITAL, LLC

Table of content: (NPI 1033862743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033862743 NPI number — GREATER PEORIA SPECIALTY HOSPITAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER PEORIA SPECIALTY HOSPITAL, LLC
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:
1033862743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 SW ADAMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61602-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-655-2850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W ROMEO B GARRETT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61605-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-680-1500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
LARGENT
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
309-655-2850

Provider Taxonomy Codes

  • Taxonomy code: 273Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 999 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com