Basic Information
Provider Information | |||||||||
NPI: | 1568414001 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST FRANCIS HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST FRANCIS HOSPITAL GENERAL SURGERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 124 SW ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | IL | ||||||||
PostalCode: | 616021320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096552850 | ||||||||
FaxNumber: | 3096554878 | ||||||||
Practice Location | |||||||||
Address1: | 3401 LUDINGTON ST | ||||||||
Address2: |   | ||||||||
City: | ESCANABA | ||||||||
State: | MI | ||||||||
PostalCode: | 498291300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9067863311 | ||||||||
FaxNumber: | 9067864004 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 07/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCGREW | ||||||||
AuthorizedOfficialFirstName: | DIANE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, OSF HEALTHCARE SYSTEM | ||||||||
AuthorizedOfficialTelephone: | 3096552850 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OSF HEALTHCARE SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 210010 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | CE9198 | 01 | MI | MEDICARE RAILROAD | OTHER | CF0141 | 01 | MI | MEDICARE RAILROAD | OTHER | 00076B | 01 | MI | BLUE CROSS | OTHER | 405171978 | 05 | MI |   | MEDICAID |