Healthcare Provider Details

I. General information

NPI: 1134173917
Provider Name (Legal Business Name): PROCTOR HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 209
PEORIA IL
61614-5098
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 209
PEORIA IL
61614-5098
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-6049
  • Fax: 309-689-6092
Mailing address:
  • Phone: 309-689-6049
  • Fax: 309-689-6092

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: CARRIE CHIARAVALLE
Title or Position: DIRECTOR
Credential:
Phone: 309-689-6049