Basic Information
Provider Information | |||||||||
NPI: | 1629598602 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JULIA RACKLEY PERRY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PERRY MEMORIAL HENRY CLINIC | ||||||||
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: | 8158754531 | ||||||||
FaxNumber: | 8158762022 | ||||||||
Practice Location | |||||||||
Address1: | 327 EDWARD ST | ||||||||
Address2: |   | ||||||||
City: | HENRY | ||||||||
State: | IL | ||||||||
PostalCode: | 615371539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8158754531 | ||||||||
FaxNumber: | 8158762022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2017 | ||||||||
LastUpdateDate: | 07/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELTE | ||||||||
AuthorizedOfficialFirstName: | JEAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL STAFF SERVICES COORD | ||||||||
AuthorizedOfficialTelephone: | 8158762293 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | JULIA RACKLEY PERRY MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 0001883 | IL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.