Provider Demographics
NPI:1033130752
Name:PEKIN MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PEKIN MEMORIAL HOSPITAL
Other - Org Name:PEKIN HOSPITAL HHC
Other - Org Type:Doing Business As
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 1:2934 COURT ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6229
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 HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-21
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1002419251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid