Basic Information
Provider Information | |||||||||
NPI: | 1952978371 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JELLICO REGIONAL HOSPITAL, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10757 RANDOLPH ST | ||||||||
Address2: |   | ||||||||
City: | CROWN POINT | ||||||||
State: | IN | ||||||||
PostalCode: | 463077615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234550245 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 188 HOSPITAL LN | ||||||||
Address2: |   | ||||||||
City: | JELLICO | ||||||||
State: | TN | ||||||||
PostalCode: | 377624400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234550245 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2021 | ||||||||
LastUpdateDate: | 06/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SINGH | ||||||||
AuthorizedOfficialFirstName: | KIRNJOT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2192284355 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X |   |   | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.