Basic Information
| Provider Information | |||||||||
| NPI: | 1114938859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAHAM HOSPITAL ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615202607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096475240 | ||||||||
| FaxNumber: | 3096495110 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615202607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096475240 | ||||||||
| FaxNumber: | 3096495110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | REEDER | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 3096475240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 203000310 | IL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 016564 | 01 | IL | HEALTH ALLIANCE | OTHER | 0002915611 | 01 | IL | BLUE CROSS BLUE SHIELD IL | OTHER |