Provider Demographics
NPI:1932150299
Name:PEKIN PROHEALTH INC
Entity Type:Organization
Organization Name:PEKIN PROHEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-353-0799
Mailing Address - Street 1:600 S 13TH ST
Mailing Address - Street 2:SUITE M
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-4936
Mailing Address - Country:US
Mailing Address - Phone:309-353-0825
Mailing Address - Fax:309-347-1246
Practice Address - Street 1:600 S 13TH ST
Practice Address - Street 2:SUITE M
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-4936
Practice Address - Country:US
Practice Address - Phone:309-353-0825
Practice Address - Fax:309-347-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09015685OtherBLUE CROSS BLUE SHIELD
ILCE8213OtherRAIL ROAD MEDICARE
ILCN0361OtherRAIL ROAD MEDICARE
IL09015685OtherBLUE CROSS BLUE SHIELD
IL779491Medicare PIN