Basic Information
| Provider Information | |||||||||
| NPI: | 1730120213 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAJOR HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | THE WATERS OF DILLSBORO-ROSS MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 FENCL LANE | ||||||||
| Address2: | |||||||||
| City: | HILLSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601622067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084491900 | ||||||||
| FaxNumber: | 7084491500 | ||||||||
| Practice Location | |||||||||
| Address1: | 12803 LENOVER ST | ||||||||
| Address2: | |||||||||
| City: | DILLSBORO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470189418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124325226 | ||||||||
| FaxNumber: | 8124323311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/07/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HORNER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3173985255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05-000178-1 | IN | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100273840C | 05 | IN | MEDICAID | 000000385604 | 01 | IN | ANTHEM BCBS OT OUTPATIENT | OTHER | 000000383032 | 01 | IN | ANTHEM BCBS | OTHER | 000000385605 | 01 | IN | ANTHEM BCBS ST OUTPATIENT | OTHER | 000000385603 | 01 | IN | ANTHEM BCBS PT OUTPATIENT | OTHER |