Healthcare Provider Details

I. General information

NPI: 1861770802
Provider Name (Legal Business Name): ST. MARGARET'S HEALTH-PERU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 BUCKLIN ST
LA SALLE IL
61301-2389
US

IV. Provider business mailing address

1305 6TH ST
PERU IL
61354-2759
US

V. Phone/Fax

Practice location:
  • Phone: 815-220-7170
  • Fax:
Mailing address:
  • Phone: 815-780-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DORI BONNELL
Title or Position: DIRECTOR OF PHYSICIAN PRACTICES
Credential:
Phone: 815-780-3222