Basic Information
| Provider Information | |||||||||
| NPI: | 1760625669 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FERRELL HOSPITAL COMMUNITY FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LOCUST STREET CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1407 LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | ELDORADO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629301629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182733361 | ||||||||
| FaxNumber: | 6182735501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | ELDORADO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629301629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182733361 | ||||||||
| FaxNumber: | 6182735501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARTLEY | ||||||||
| AuthorizedOfficialFirstName: | H | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6184733361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.