1649210444 NPI number — PASSAVANT MEMORIAL AREA HOSPITAL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649210444 NPI number — PASSAVANT MEMORIAL AREA HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PASSAVANT MEMORIAL AREA 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:
THE CENTER FOR PSYCHIATRIC HEALTH
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:
1649210444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1977
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62705-1977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-544-6464
Provider Business Mailing Address Fax Number:
217-757-6021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
557 N WESTGATE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62650-1156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-245-7275
Provider Business Practice Location Address Fax Number:
217-245-7427
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAGEL
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO/VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
217-479-5527

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 06932018 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CB3741 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 681484 . This is a "HEALTHLINK PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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