Healthcare Provider Details

I. General information

NPI: 1275583155
Provider Name (Legal Business Name): METHODIST MEDICAL CENTER OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
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

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax: 309-671-2541
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number0001594
License Number StateIL

VIII. Authorized Official

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