Petersen Management Company, LLC

Primary specialty

Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X

License

0039800 Issued in IL

Legal business name

PETERSEN MANAGEMENT COMPANY, LLC

Doing business as

Mt. Vernon Health Care Center

Practice address

5 Doctors Park Rd
Mount Vernon, IL 62864-6224

Phone

(618) 242-1064

Fax

(618) 242-7559

NPI assigned

Oct 23, 2006

Last updated

May 30, 2013By the provider in NPPES

Organization subpart

Yes

Parent organization

PETERSEN HEALTH CARE II, INC.As reported in NPPES

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

• Mt. Vernon Health Care Center Doing business as

Part of

Petersen Health Care II Inc

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

{
    "created_epoch": "1161561600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1369872000000",
    "number": "1780767897",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "830 W TRAILCREEK DR",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616141862",
            "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": "5 DOCTORS PARK RD",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628646224",
            "telephone_number": "618-242-1064",
            "fax_number": "618-242-7559"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSEN MANAGEMENT COMPANY, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PETERSEN HEALTH CARE II, INC.",
        "enumeration_date": "2006-10-23",
        "last_updated": "2013-05-30",
        "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": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "IL",
            "license": "0039800",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "391516877001",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mt. Vernon Health Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Marsha Perfetti-McIntosh
• Michael Patrick Henry Perkins, CRNA
• Edward E Perry, O.D.
• Kimberly Lisa Joan Perry, LPN
• Petersen Health Care LL, Inc. (New Horizons Rehabilitation & Health Care Center)
• Petersen Management Company, LLC (White Oak Rehabilitation & Health Care Center)
• Cynthia Dawn Phillips, APN
• Jaylyn Phillips
• Shima Phoenix, DMD
• Physician Rural Health Clinic of Jefferson County

• Nursing Facility/Intermediate Care Facility in Mount Vernon, IL
• Providers in Mount Vernon, IL by specialty
• Nursing Facility/Intermediate Care Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 30, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.