Basic Information
| Provider Information | |||||||||
| NPI: | 1033130752 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEKIN MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEKIN HOSPITAL HHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615544936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093530406 | ||||||||
| FaxNumber: | 3093471240 | ||||||||
| Practice Location | |||||||||
| Address1: | 2934 COURT ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093530406 | ||||||||
| FaxNumber: | 3093471240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | JEPSON | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3093530756 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEKIN MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1002419 | IL | Y | Agencies | Home Health |
No ID Information.