Basic Information
| Provider Information | |||||||||
| NPI: | 1164666988 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARSHALL BROWNING HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARSHALL BROWNING HOSPITAL PHYSICIANS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 192 | ||||||||
| Address2: | |||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628320192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185422146 | ||||||||
| FaxNumber: | 6185425920 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628321230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185422146 | ||||||||
| FaxNumber: | 6185425920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPOUR | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6185422146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHALL BROWNING HOSPITAL ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 0001388 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 244 | 01 | IL | BLUE CROSS | OTHER | 272980 | 01 | IL | HEALTHLINK | OTHER | 7315813 | 01 | IL | BLUE SHIELD | OTHER | CF1574 | 01 | IL | PALMATO-GBA / RRMC-GROUP | OTHER | 807200 | 01 | IL | MEDICARE ID PART B | OTHER |