Basic Information
| Provider Information | |||||||||
| NPI: | 1366506628 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RURAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DONGOLA MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 513 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629061668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188334471 | ||||||||
| FaxNumber: | 6188338878 | ||||||||
| Practice Location | |||||||||
| Address1: | 318 N US HIGHWAY 51 | ||||||||
| Address2: | |||||||||
| City: | DONGOLA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188273545 | ||||||||
| FaxNumber: | 6188274891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLAMM | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | C. E. O. | ||||||||
| AuthorizedOfficialTelephone: | 6188334471 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RURAL HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 9115001 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 111760 | 01 | IL | HEALTHLINK | OTHER | 055761 | 01 | IL | HEALTH ALLIANCE | OTHER |