Provider Demographics
NPI:1164474755
Name:METHODIST MEDICAL CENTER OF ILLINOIS
Entity Type:Organization
Organization Name:METHODIST MEDICAL CENTER OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:KNEPP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:309-671-2528
Mailing Address - Street 1:221 NE GLEN OAK AVE
Mailing Address - Street 2:GOMP 100
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636
Practice Address - Country:US
Practice Address - Phone:309-672-5522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001594282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0116OtherBLUE CROSS PROV. NUMBER
IL0116OtherBLUE CROSS PROV. NUMBER
IL=========001Medicaid
IL827160Medicare PIN
IL827130Medicare PIN
IL0116OtherBLUE CROSS PROV. NUMBER
IL211369Medicare PIN