Healthcare Provider Details

I. General information

NPI: 1710198379
Provider Name (Legal Business Name): METHODIST MEDICAL CENTER OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

5271 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 309-672-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
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