Basic Information
| Provider Information | |||||||||
| NPI: | 1588679898 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JELLICO COMMUNITY HOSPITAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JELLICO COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844869 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841334 | ||||||||
| FaxNumber: | 4237841336 | ||||||||
| Practice Location | |||||||||
| Address1: | 188 HOSPITAL LAN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841334 | ||||||||
| FaxNumber: | 4237841136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GHULAM | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4237841334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 0000000007 | TN | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 397905000 | 01 | TN | FEDERAL BLACK LUNG | OTHER | 440180 | 01 | TN | TC AMBULANCE | OTHER | 54976 | 01 | TN | ONE NATION OLD ANTHEM BE | OTHER | 1530476 | 01 | TN | UNITED MINE WORKERS | OTHER | 440180 | 01 | TN | MEDICARE MANAGED CARE | OTHER | A3776201 | 01 | TN | TC AMBULANCE | OTHER | A3776201 | 01 | TN | JOHN DEERE COMMERCIAL | OTHER | 55620496 | 01 | TN | UNISYS AMBULANCE | OTHER | 6530360 | 01 | TN | AETNA | OTHER | 0440180 | 05 | TN | MEDICAID | 162084800 | 05 | KY | MEDICAID | 1000250 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | 450003829 | 01 | TN | KY MEDICAID EPSDT | OTHER | 54976 | 01 | TN | ANTHEM BLUE CROSS | OTHER |