Basic Information
| Provider Information | |||||||||
| NPI: | 1437103454 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GENESIS MEDICAL CENTER - ILLINI CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 801 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612821804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097929363 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612821804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097929363 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRUHN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3097924265 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | IL | X | Hospitals | General Acute Care Hospital | 341600000X | IL | X | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 0715789 | 05 | IA | MEDICAID | 40275 | 01 | IA | BLUE CROSS IA UB | OTHER | 005428 | 01 | HEALTH ALLIANCE | OTHER | 0373 | 01 | IL | BLUE CROSS IL | OTHER | A6128203 | 01 | JDHC UB | OTHER | CK0986 | 01 | IL | RR MEDICARE | OTHER | 97195 | 01 | IA | BLUE CROSS IA 1500 EKG | OTHER | 0811526977 | 01 | IL | BLUE CORSS IL 1500 | OTHER | 0927640 | 05 | IA | MEDICAID | 0973867 | 05 | IA | MEDICAID | 96922 | 01 | IA | BLUE CROSS 1500 ED | OTHER |