Provider Demographics
NPI:1720223837
Name:PROCTOR HEALTH SYSTEMS
Entity Type:Organization
Organization Name:PROCTOR HEALTH SYSTEMS
Other - Org Name:PROCTOR MEDICAL GROUP SURGERY - C K SONG MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEM ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:390-689-6089
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:STE 209
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-691-1092
Mailing Address - Fax:309-689-6092
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:STE 217
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-691-1092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROCTOR HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical