Basic Information
| Provider Information | |||||||||
| NPI: | 1487978227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | GALENA STAUSS NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GALENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610368118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157771340 | ||||||||
| FaxNumber: | 8157767274 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | GALENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610361635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157767255 | ||||||||
| FaxNumber: | 8157767298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2010 | ||||||||
| LastUpdateDate: | 12/08/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHEAHEN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8157767266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0049718 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 362487178002 | 05 | IL | MEDICAID |