Basic Information
| Provider Information | |||||||||
| NPI: | 1578544896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY HOSPITAL ANDERSON ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6233 RELIABLE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178026314 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 N MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460113453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178026314 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7652985120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200472580A | 05 | IN | MEDICAID |