Provider Demographics
NPI:1407028780
Name:JULIA RACKLEY PERRY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JULIA RACKLEY PERRY MEMORIAL HOSPITAL
Other - Org Name:PERRY MEMORIAL PODIATRY CLINIC
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:
Practice Address - Street 1:530 PARK AVE E STE 306
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3903
Practice Address - Country:US
Practice Address - Phone:815-876-3033
Practice Address - Fax:815-876-3003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JULIA RACKLEY PERRY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-27
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1407028780Medicaid