1750353041 NPI number — NATIONAL HEALTHCARE OF MT VERNON INC

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 1750353041 NPI number — NATIONAL HEALTHCARE OF MT VERNON INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATIONAL HEALTHCARE OF MT VERNON INC
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:
1750353041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60548
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63160-0548
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:
8 DOCTORS PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864-6224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-244-5500
Provider Business Practice Location Address Fax Number:
618-244-5566
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
SVP FINANCE OPERATIONS/AO
Authorized Official Telephone Number:
615-221-3840

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  0003947 , 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: 288089 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 011701901 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 614753 . This is a "BOILERMAKERS" identifier . This identifiers is of the category "OTHER".




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