Basic Information
| Provider Information | |||||||||
| NPI: | 1134387988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILLSBORO MEDICAL CENTER AT NOKOMIS LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S STATE STREET | ||||||||
| Address2: | |||||||||
| City: | NOKOMIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620751341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 S STATE STREET | ||||||||
| Address2: | |||||||||
| City: | NOKOMIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620751341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2175287541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPRINGFIELD CLINIC LLP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 14D1071840 | 01 | CLIA | OTHER |