Provider Demographics
NPI:1124021308
Name:JULIA RACKLEY PERRY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JULIA RACKLEY PERRY MEMORIAL HOSPITAL
Other - Org Name:PERRY MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL STAFF SERVICES COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-876-2293
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:815-875-2811
Mailing Address - Fax:815-876-4455
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3901
Practice Address - Country:US
Practice Address - Phone:815-875-2811
Practice Address - Fax:815-876-4455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001883282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL122OtherBLUE CROSS
IL336006057401Medicaid
IL336006057001Medicaid
IL001193OtherHEALTH ALLIANCE
ILA61356001OtherJOHN DEERE
IL336006057001Medicaid
IL141337Medicare Oscar/Certification