Provider Demographics
NPI:1306978457
Name:PEKIN MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:PEKIN MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JEPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-353-0756
Mailing Address - Street 1:600 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-4936
Mailing Address - Country:US
Mailing Address - Phone:309-353-0406
Mailing Address - Fax:309-347-1240
Practice Address - Street 1:600 S 13TH ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-4936
Practice Address - Country:US
Practice Address - Phone:309-353-0406
Practice Address - Fax:309-347-1240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEKIN MEMORIAL HOSPTIAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-12
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001834367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
921650Medicare Oscar/Certification