1639187149 NPI number — SPARTA COMMUNITY HOSPITAL

Table of content: (NPI 1639187149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639187149 NPI number — SPARTA COMMUNITY HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPARTA COMMUNITY 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:
AT-HOME HEALTH CARE
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:
1639187149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2023
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:
203 S. VINE STREET
Provider Second Line Business Practice Location Address:
BROADWAY PLAZA SUITE 5
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-443-2177
Provider Business Practice Location Address Fax Number:
618-443-1354
Provider Enumeration Date:
08/03/2006

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:
618-443-2177

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1009653 , 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: 5080 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: ========= , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1009653 . This is a "IDPH ID NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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