MEDICARE: JULIA RACKLEY PERRY MEMORIAL HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NC0060X	Critical Access Hospital	0001883	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	122	OTHER	IL	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	001193	OTHER	IL	HEALTH ALLIANCE
5	A61356001	OTHER	IL	JOHN DEERE

General Provider Information

NPI Number	:	1124021308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JULIA RACKLEY PERRY MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	530 PARK AVE E
Second Line	:
City	:	PRINCETON
State	:	IL
Zip	:	61356-3901
Country	:	US
Telephone Number	:	815-875-2811
Fax Number	:	815-876-4455

Provider Business Practice Location Address
First Line	:	530 PARK AVE E
Second Line	:
City	:	PRINCETON
State	:	IL
Zip	:	61356-3901
Country	:	US
Telephone Number	:	815-875-2811
Fax Number	:	815-876-4455

Authorized Official
Title or Position	:	MEDICAL STAFF SERVICES COORDINATOR
Name	:	JEAN WELTE
Credential	:
Telephone Number	:	815-876-2293

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	03/17/2020

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