Basic Information
Provider Information
NPI: 1760994040
EntityType: 2
ReplacementNPI:  
OrganizationName: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
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Credential:  
OtherOrganizationName: PASSAVANT PROFESSIONAL SERVICES
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
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Mailing Information
Address1: 1600 W WALNUT ST
Address2:  
City: JACKSONVILLE
State: IL
PostalCode: 626501136
CountryCode: US
TelephoneNumber: 2172459541
FaxNumber: 2174798781
Practice Location
Address1: 1600 W WALNUT ST
Address2:  
City: JACKSONVILLE
State: IL
PostalCode: 626501136
CountryCode: US
TelephoneNumber: 2172459541
FaxNumber: 2174798781
Other Information
ProviderEnumerationDate: 10/26/2017
LastUpdateDate: 04/09/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SILTMAN
AuthorizedOfficialFirstName: ROBERT
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: DIRECTOR, PATIENT FINCNAIAL SERVICE
AuthorizedOfficialTelephone: 2174795652
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION
AuthorizedOfficialNamePrefix:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
363L00000X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
207R00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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