Basic Information
| Provider Information | |||||||||
| NPI: | 1659552859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOSEPH MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | OSF SAINT JOSEPH MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033255 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2200 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617014364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096623311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCGREW | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3096552850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSF HEALTHCARE SYSTEM | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000 | 05 | IL | MEDICAID | 5715388 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |