Provider Demographics
NPI:1033116876
Name:PROCTOR COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:PROCTOR COMMUNITY HOSPITAL
Other - Org Name:PROCTOR HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-672-5928
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:309-672-4813
Mailing Address - Fax:309-671-8265
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:309-671-8265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1677264282N00000X
IL0001925282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0117OtherBLUE CROSS
IL140013Medicare ID - Type Unspecified
IL140013Medicare Oscar/Certification
IL=========0001Medicaid
IL140013Medicare Oscar/Certification