Basic Information
| Provider Information | |||||||||
| NPI: | 1558088203 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OTTAWA REGIONAL HOSPITAL & HEALTHCARE CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OSF HEALTHCARE - MEDICAL GROUP (NON-RHC BILLING) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SW ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096552850 | ||||||||
| FaxNumber: | 3096554878 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 11TH ST | ||||||||
| Address2: | |||||||||
| City: | MARSEILLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613411048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157955400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2022 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEHRING | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | CARL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3096557869 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSF HEALTHCARE SYSTEM | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 999 | 05 | IL | MEDICAID |