Provider Demographics
NPI:1487624318
Name:PROCTOR COMMUNITY HOSPITAL
Entity type:Organization
Organization Name:PROCTOR COMMUNITY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MGR REIMB/REV RECOGNITION
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CIRONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-672-4813
Mailing Address - Street 1:5409 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5016
Mailing Address - Country:US
Mailing Address - Phone:309-691-1000
Mailing Address - Fax:
Practice Address - Street 1:5409 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5016
Practice Address - Country:US
Practice Address - Phone:309-691-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROCTOR HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1009695251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid
IL=========006Medicaid