Healthcare Provider Details

I. General information

NPI: 1124305636
Provider Name (Legal Business Name): METHODIST MEDICAL CENTER OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S GRISWOLD ST
PEORIA IL
61605-1458
US

IV. Provider business mailing address

5100 RELIABLE PKWY
CHICAGO IL
60686-0051
US

V. Phone/Fax

Practice location:
  • Phone: 309-685-8390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
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