Petersen Health Care - Illini, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

0042440 Issued in IL

Legal business name

PETERSEN HEALTH CARE - ILLINI, LLC

Doing business as

Illini Heritage Rehab & Health Care

Practice address

1315 Curt Drive
Champaign, IL 61820

Phone

(217) 352-5707

Fax

(217) 352-2607

NPI assigned

Aug 22, 2006

Last updated

Feb 14, 2024By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mark B. Petersen

Title

President

Phone

(309) 691-8113

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Illini Heritage Rehab & Health Care Doing business as

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

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

{
    "created_epoch": "1156204800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707868800000",
    "number": "1619083730",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "830 W. TRAILCREEK DRIVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "61614",
            "telephone_number": "309-691-8113",
            "fax_number": "309-691-8622"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1315 CURT DRIVE",
            "city": "CHAMPAIGN",
            "state": "IL",
            "postal_code": "61820",
            "telephone_number": "217-352-5707",
            "fax_number": "217-352-2607"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSEN HEALTH CARE - ILLINI, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-22",
        "last_updated": "2024-02-14",
        "certification_date": "2024-02-14",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "B.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "309-691-8113"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "0042440",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300318970007",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Illini Heritage Rehab & Health Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jacob Perkins, DPM
• Erica Anne Person, M.D.
• Nicholas John Peterman
• Kathleen Peters
• Vanessa Ann Peters, MD, PHD
• Jaclyn Annette Petersen, MSW
• John Peterson, M.D.
• Nancy T. Peterson, L.C.S.W.
• Mary Petre
• Tamara Petrovich, PHARMD

• Skilled Nursing Facility in Champaign, IL
• Providers in Champaign, IL by specialty
• Skilled Nursing Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2024; 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.