Healthcare Provider Details

I. General information

NPI: 1407174873
Provider Name (Legal Business Name): METHODIST MEDICAL CENTER OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 5TH ST
LACON IL
61540
US

IV. Provider business mailing address

5100 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-246-2676
  • Fax: 309-246-3574
Mailing address:
  • Phone:
  • 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 Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN M. CIRONE
Title or Position: REGIONAL MGR-REIMB/REV RECOGNITION
Credential:
Phone: 309-672-4813