Provider Demographics
NPI:1821068404
Name:PROCTOR COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:PROCTOR COMMUNITY HOSPITAL
Other - Org Name:PROCTOR HOSPITAL SKILLED NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-672-5928
Mailing Address - Street 1:5409 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5016
Mailing Address - Country:US
Mailing Address - Phone:309-672-4813
Mailing Address - Fax:309-671-8265
Practice Address - Street 1:5409 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5016
Practice Address - Country:US
Practice Address - Phone:309-691-1000
Practice Address - Fax:309-671-8265
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROCTOR COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-25
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1677264314000000X
IL0001925314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145579Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IL145579Medicare Oscar/Certification