Basic Information
Provider Information | |||||||||
NPI: | 1629039706 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINCKNEYVILLE COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5383 STATE ROUTE 154 | ||||||||
Address2: |   | ||||||||
City: | PINCKNEYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622743342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183572187 | ||||||||
FaxNumber: | 6183578888 | ||||||||
Practice Location | |||||||||
Address1: | 5383 STATE ROUTE 154 | ||||||||
Address2: |   | ||||||||
City: | PINCKNEYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622743342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183572187 | ||||||||
FaxNumber: | 6183578888 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2006 | ||||||||
LastUpdateDate: | 01/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARSON | ||||||||
AuthorizedOfficialFirstName: | KARA | ||||||||
AuthorizedOfficialMiddleName: | JO | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6183575902 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PINCKNEYVILLE COMMUNITY HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MACC, CPA, CHFP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X |   |   | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 003663 | 01 | IL | HEALTH ALLIANCE HOSPITAL | OTHER | 111948 | 01 | IL | HEALTHLINK PROVIDER ID | OTHER | 162116 | 01 | IL | UNITED HEALTHCARE ID | OTHER |