Basic Information
| Provider Information | |||||||||
| NPI: | 1033649967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JULIA RACKLEY PERRY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PERRY MEMORIAL WALNUT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 PARK AVE E | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613563901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158764419 | ||||||||
| FaxNumber: | 8158764455 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 N MAIN ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | WALNUT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613769707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153792020 | ||||||||
| FaxNumber: | 8153792018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELTE | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF SERVICES COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8158762293 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JULIA RACKLEY PERRY MEMORIAL HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 0001883 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.