1114984226 NPI number — SPARTA COMMUNITY HOSPITAL D/B/A QUALITY HEALTHCARE CLINICS

Table of content: (NPI 1114984226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114984226 NPI number — SPARTA COMMUNITY HOSPITAL D/B/A QUALITY HEALTHCARE CLINICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPARTA COMMUNITY HOSPITAL D/B/A QUALITY HEALTHCARE CLINICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SPARTA COMMUNITY HOSPITAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114984226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 297
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62286-0297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-443-1337
Provider Business Mailing Address Fax Number:
618-443-1383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 E. BROADWAY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62286-0297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-443-1337
Provider Business Practice Location Address Fax Number:
618-443-1383
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ERNSTING
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
618-433-2177

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CH0349 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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