NPIMap

Organization Active NPI

Proctor Health Systems

Doing business as Proctor Medical Group Renaldo Jacques MD

  • Clinic/Center
  • Peoria, IL
National Provider Identifier
1396923702
Registry record updated Feb 7, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
PROCTOR HEALTH SYSTEMS
Doing business as
Proctor Medical Group Renaldo Jacques MD
Practice address
5401 N Knoxville Ave Ste 306
Peoria, IL 61614-5021
Phone
(309) 691-0027
NPI assigned
Feb 7, 2008
Last updated
Feb 7, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 7, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Carrie Chiaravalle
Title
Director Operations
Phone
(309) 689-6043

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary

Addresses

Primary practice location

5401 N Knoxville Ave Ste 306
Peoria, IL 61614-5021

Mailing address

5401 N Knoxville Ave Ste 306
Peoria, IL 61614-5021

Other identifiers 1

IdentifierTypeStateIssuer
07232122OtherILBCBSIL

Other names 1

  • PROCTOR MEDICAL GROUP RENALDO JACQUES MD Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040227000906 IL Part B Supplier - Clinic/Group Practice 3476440173 Receives reassigned benefits from 378 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Galesburg, IL; Washington, IL; Spring Valley, IL; Princeton, IL; Peoria, IL; Pekin, IL; Morton, IL; Metamora, IL…

Other NPIs on the same Medicare enrollment 10

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

5401 N Knoxville Ave
Ste 306
Peoria, IL 61614
Phone (309) 689-0044

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1202342400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1202342400000",
    "number": "1396923702",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5401 N KNOXVILLE AVE STE 306",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616145021"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5401 N KNOXVILLE AVE STE 306",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616145021",
            "telephone_number": "309-691-0027"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROCTOR HEALTH SYSTEMS",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-07",
        "last_updated": "2008-02-07",
        "status": "A",
        "authorized_official_last_name": "CHIARAVALLE",
        "authorized_official_first_name": "CARRIE",
        "authorized_official_title_or_position": "DIRECTOR OPERATIONS",
        "authorized_official_telephone_number": "309-689-6043"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSIL",
            "identifier": "07232122",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROCTOR MEDICAL GROUP RENALDO JACQUES MD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Peoria, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 7, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.