Basic Information
| Provider Information | |||||||||
| NPI: | 1356365670 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTON MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EUNICE SMITH HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11133 DUNN RD | ||||||||
| Address2: | PFD 2ND FLOOR SUITE 2179 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146534093 | ||||||||
| FaxNumber: | 3146534077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637330 | ||||||||
| FaxNumber: | 6184637332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRAASCH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6184637301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0008409 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 46497 | 01 | GHP | OTHER | 0000000709 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 7100035 | 01 | UNITED HEALTHCARE | OTHER |