Provider Demographics
NPI:1407872997
Name:MENDOTA COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:MENDOTA COMMUNITY HOSPITAL
Other - Org Name:PHYSICIAN SERVICES OF MCH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO, OSF HEALTHCARE SYSTEM
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:SEHRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:306-655-2850
Mailing Address - Street 1:124 SW ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1320
Mailing Address - Country:US
Mailing Address - Phone:093-655-2850
Mailing Address - Fax:309-655-4878
Practice Address - Street 1:1401 EAST 12TH STREET
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-9216
Practice Address - Country:US
Practice Address - Phone:815-539-7461
Practice Address - Fax:815-538-5516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001537207Q00000X, 207X00000X, 208600000X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI2549OtherRAILROAD MEDICARE
IL461700Medicare Oscar/Certification