Basic Information
| Provider Information | |||||||||
| NPI: | 1568463701 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JERSEY COMMUNITY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JERSEY COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 MAPLE SUMMIT RD | ||||||||
| Address2: | PO BOX 426 | ||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184986402 | ||||||||
| FaxNumber: | 6184988496 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MAPLE SUMMIT RD | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184986402 | ||||||||
| FaxNumber: | 6184988496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAR | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | PHILIP | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6184988300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0001156 | IL | Y | Hospitals | General Acute Care Hospital |
No ID Information.