Basic Information
| Provider Information | |||||||||
| NPI: | 1306818844 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINCKNEYVILLE COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5383 STATE ROUTE 154 | ||||||||
| Address2: | |||||||||
| City: | PINCKNEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622743342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183572187 | ||||||||
| FaxNumber: | 6183578888 | ||||||||
| Practice Location | |||||||||
| Address1: | 5383 STATE ROUTE 154 | ||||||||
| Address2: | |||||||||
| City: | PINCKNEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622743342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183572187 | ||||||||
| FaxNumber: | 6183578888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 01/26/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARSON | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6183572187 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINCKNEYVILLE COMMUNITY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 07320380 | 01 | IL | BCBS | OTHER | CI9857 | 01 | IL | MEDICARE RAILROAD | OTHER | 342557 | 01 | IL | HEALTHLINK | OTHER |