Basic Information
| Provider Information | |||||||||
| NPI: | 1134236748 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAHAM HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GRAHAM HOSPITAL EXTENDED CARE FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615202444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096475240 | ||||||||
| FaxNumber: | 3096495110 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615202444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096475240 | ||||||||
| FaxNumber: | 3096495110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REEDER | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 3096475240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000869 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0921 | 01 | IL | BLUE CROSS BLUE SHIELD IL | OTHER |