Basic Information
| Provider Information | |||||||||
| NPI: | 1891024584 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCDONOUGH COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MCDONOUGH DISTRICT HOSPITAL PSYCHIATRY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E GRANT ST | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614553313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098334101 | ||||||||
| FaxNumber: | 3098361525 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 E GRANT ST | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614553352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098366400 | ||||||||
| FaxNumber: | 3098365001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2009 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOPPER | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3098334101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0001438 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0005519706 | 01 | IL | BLUE CROSS | OTHER |