1619083730 NPI number — PETERSEN HEALTH CARE - ILLINI, LLC

Table of content: (NPI 1619083730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619083730 NPI number — PETERSEN HEALTH CARE - ILLINI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETERSEN HEALTH CARE - ILLINI, 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:
1619083730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 W. TRAILCREEK DRIVE
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:
61614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-691-8113
Provider Business Mailing Address Fax Number:
309-691-8622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 CURT DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-352-5707
Provider Business Practice Location Address Fax Number:
217-352-2607
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-691-8113

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0042440 , 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)

  • Identifier: 300318970007 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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