Provider Demographics
NPI:1134173917
Name:PROCTOR HEALTH SYSTEMS
Entity type:Organization
Organization Name:PROCTOR HEALTH SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIARAVALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-689-6049
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-689-6049
Mailing Address - Fax:309-689-6092
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-689-6049
Practice Address - Fax:309-689-6092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7232122OtherBC BS OF ILLINOIS
ILCD8124OtherRAILROAD MEDICARE
ILCD8123OtherRAILROAD MEDICARE
IL242904Medicare ID - Type Unspecified
ILCD8124OtherRAILROAD MEDICARE
ILCD8123OtherRAILROAD MEDICARE
IL242901Medicare ID - Type Unspecified
IL242900Medicare ID - Type Unspecified