1083685986 NPI number — GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC

Table of content: (NPI 1083685986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083685986 NPI number — GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC
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:
Provider Other Organization Name Type Code:
6
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:
1083685986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 503706
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63150-3706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62040-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-798-3000
Provider Business Practice Location Address Fax Number:
618-798-3724
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
TARA
Authorized Official Middle Name:
PEEK
Authorized Official Title or Position:
VP OF PATIENT FINANCIAL SERVICES
Authorized Official Telephone Number:
615-221-3672

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X , with the licence number:  0005223 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 0005223 , 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: 010779809 . This is a "MO MCAID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 10685 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10685 . This is a "BC MO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5020040 . This is a "HARRINGTON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103244 . This is a "HEALTHLINK PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50040 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com