Basic Information
Provider Information | |||||||||
NPI: | 1679698054 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEKIN HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 SO 13TH STREET | ||||||||
Address2: |   | ||||||||
City: | PEKIN | ||||||||
State: | IL | ||||||||
PostalCode: | 61554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3093530406 | ||||||||
FaxNumber: | 3093471240 | ||||||||
Practice Location | |||||||||
Address1: | 600 SO 13TH STREET | ||||||||
Address2: |   | ||||||||
City: | PEKIN | ||||||||
State: | IL | ||||||||
PostalCode: | 61554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3093530406 | ||||||||
FaxNumber: | 3093471240 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2007 | ||||||||
LastUpdateDate: | 07/06/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JEPSON | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3093530756 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0001834 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 207PE0004X | 0001834 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
ID | Type | State | Issuer | Description | 0009015677 | 01 | IL | BLUE CROSS PROFESSIONAL F | OTHER |