Basic Information
| Provider Information | |||||||||
| NPI: | 1164474755 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METHODIST MEDICAL CENTER OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 NE GLEN OAK AVE | ||||||||
| Address2: | GOMP 100 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616360001 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 221 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096725522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | CIRONE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER - REIMBURSEMENT RECOGNITION | ||||||||
| AuthorizedOfficialTelephone: | 3096724813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0001594 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0116 | 01 | IL | BLUE CROSS PROV. NUMBER | OTHER |