Basic Information
| Provider Information | |||||||||
| NPI: | 1841473238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GENESIS MEDICAL CENTER ILLINI CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612821804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097929363 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612821804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097929363 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEINSCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5635216513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | IL | N | Transportation Services | Ambulance | 282N00000X | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0973867 | 05 | IA | MEDICAID | 0715789 | 05 | IA | MEDICAID |