Basic Information
| Provider Information | |||||||||
| NPI: | 1417973900 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENDOTA COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OSF SAINT PAUL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SW ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096552850 | ||||||||
| FaxNumber: | 3096554878 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 EAST 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | MENDOTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613429216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155397461 | ||||||||
| FaxNumber: | 8155385516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGREW | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, OSF HEALTHCARE SYSTEM | ||||||||
| AuthorizedOfficialTelephone: | 3096552850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0001537 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000 | 05 | IL | MEDICAID | CI2549 | 01 | RAILROAD MEDICARE | OTHER |