Basic Information
| Provider Information | |||||||||
| NPI: | 1932148236 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOSEPH MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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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: | 616033200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096552850 | ||||||||
| FaxNumber: | 3096554878 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617014364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096623311 | ||||||||
| FaxNumber: | 3096627143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEHRING | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | CARL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3096557804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSF HEALTHCARE SYSTEM | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0002535 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0100 | 01 | IL | BLUE CROSS | OTHER |