1215961818 NPI number — COUNTY OF MERCER HOSPITAL

Table of content: (NPI 1215961818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215961818 NPI number — COUNTY OF MERCER HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF MERCER HOSPITAL
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:
MEDICAL ASSOCIATES CLINIC
Provider Other Organization Name Type Code:
3
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:
1215961818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 NW 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEDO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61231-1296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-582-3700
Provider Business Mailing Address Fax Number:
309-582-3737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1007 NW 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEDO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61231-1296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-582-3700
Provider Business Practice Location Address Fax Number:
309-582-3737
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROGALSKI
Authorized Official First Name:
TED
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
309-582-3700

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0006632002 . This is a "BLUE CROSS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 210481 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 825050 . This is a "MEDICARE B" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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