Healthcare Provider Details

I. General information

NPI: 1679698054
Provider Name (Legal Business Name): PEKIN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 SO 13TH STREET
PEKIN IL
61554
US

IV. Provider business mailing address

600 SO 13TH STREET
PEKIN IL
61554
US

V. Phone/Fax

Practice location:
  • Phone: 309-353-0406
  • Fax: 309-347-1240
Mailing address:
  • Phone: 309-353-0406
  • Fax: 309-347-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0001834
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number0001834
License Number StateIL

VIII. Authorized Official

Name: GARY JEPSON
Title or Position: CEO
Credential:
Phone: 309-353-0756