Basic Information
| Provider Information | |||||||||
| NPI: | 1326408204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JULIA RACKLEY PERRY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PERRY MEMORIAL PROMPT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 530 PARK AVE E | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613563901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158764419 | ||||||||
| FaxNumber: | 8158764455 | ||||||||
| Practice Location | |||||||||
| Address1: | 2128 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613569728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158752273 | ||||||||
| FaxNumber: | 8152078682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELTE | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF SERVICES COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8158762293 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 0001883 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.