Basic Information
| Provider Information | |||||||||
| NPI: | 1952335192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNION HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORK MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2505 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387783 | ||||||||
| FaxNumber: | 8122384506 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624411010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178262361 | ||||||||
| FaxNumber: | 2178262366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | PALLUTCH | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8122387000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNION HOSPITAL INCORPORATED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 148987 | 01 | IL | RIVERBEND | OTHER | CH2578 | 01 | IL | RR MEDICARE | OTHER | 200074840J | 05 | IN | MEDICAID |