NPIMap

Organization Active NPI

Proctor Health Systems

Doing business as Lake of the Woods Medical Center

  • Primary Care Clinic/Center
  • Dunlap, IL
National Provider Identifier
1629022447
Registry record updated Aug 7, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
PROCTOR HEALTH SYSTEMS
Doing business as
Lake of the Woods Medical Center
Practice address
12315 N Knoxville Ave
Dunlap, IL 61525-9501
Phone
(309) 243-5575
Fax
(309) 243-5764
NPI assigned
May 19, 2006
Last updated
Aug 7, 2007By the provider in NPPES
Organization subpart
Yes
Parent organization
PROCTOR HEALTH SYSTEMSAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 7, 2007

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

Authorized official

Name
Carrie Chiaravalle
Title
Director
Phone
(309) 689-6049

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X Primary

Addresses

Primary practice location

12315 N Knoxville Ave
Dunlap, IL 61525-9501

Mailing address

5401 N Knoxville Ave
Suite 209
Peoria, IL 61614-5098
Phone (309) 689-6049

Other names 1

  • LAKE OF THE WOODS MEDICAL CENTER 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
Part of
Lacon Clinic

NPI Registry JSON

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1186444800000",
    "number": "1629022447",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5401 N KNOXVILLE AVE",
            "address_2": "SUITE 209",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616145098",
            "telephone_number": "309-689-6049",
            "fax_number": "309-689-6092"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12315 N KNOXVILLE AVE",
            "city": "DUNLAP",
            "state": "IL",
            "postal_code": "615259501",
            "telephone_number": "309-243-5575",
            "fax_number": "309-243-5764"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROCTOR HEALTH SYSTEMS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROCTOR HEALTH SYSTEMS",
        "enumeration_date": "2006-05-19",
        "last_updated": "2007-08-07",
        "status": "A",
        "authorized_official_last_name": "CHIARAVALLE",
        "authorized_official_first_name": "CARRIE",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "309-689-6049"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LAKE OF THE WOODS MEDICAL CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dunlap, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2007; 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.