Basic Information
| Provider Information | |||||||||
| NPI: | 1699794578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JELLICO COMMUNITY HOSPITAL INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | JELLICO COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 844869 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841334 | ||||||||
| FaxNumber: | 4237841336 | ||||||||
| Practice Location | |||||||||
| Address1: | 188 HOSPITAL LANE | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841334 | ||||||||
| FaxNumber: | 4237841136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GHULAM | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4237841334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 0000000007 | TN | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 01620848 | 05 | KY | MEDICAID | 1000250 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 1530476 | 01 | TN | UNITED MINE WORKERS | OTHER | A3776201 | 01 | TN | JOHN DEERE COMMERCIAL | OTHER | 0440180 | 05 | TN | MEDICAID | 1000250 | 01 | TN | TC AMBULANCE | OTHER | 6530360 | 01 | TN | AETNA | OTHER | A3776201 | 01 | TN | TC AMBULANCE | OTHER | 397905000 | 01 | TN | FEDERAL BLACK LUNG | OTHER | 440180 | 01 | TN | MEDICARE MANAGED CARE | OTHER | 440180 | 01 | TN | TC AMBULANCE | OTHER | 54976 | 01 | TN | ANTHEM BLUE CROSS | OTHER | 55620496 | 01 | TN | UNISYS AMBULANCE | OTHER |