Provider Demographics
NPI:1679698054
Name:PEKIN HOSPITAL
Entity Type:Organization
Organization Name:PEKIN HOSPITAL
Other - Org Name:
Other - Org Type:
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 SO 13TH STREET
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554
Mailing Address - Country:US
Mailing Address - Phone:309-353-0406
Mailing Address - Fax:309-347-1240
Practice Address - Street 1:600 SO 13TH STREET
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554
Practice Address - Country:US
Practice Address - Phone:309-353-0406
Practice Address - Fax:309-347-1240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001834207PE0004X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009015677OtherBLUE CROSS PROFESSIONAL F