Basic Information
| Provider Information | |||||||||
| NPI: | 1467549402 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOOPESTON COMMUNITY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARLE AT WATSEKA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 1490 E WALNUT ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | WATSEKA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609701806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154328200 | ||||||||
| FaxNumber: | 8154328201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | BROCKUS | ||||||||
| AuthorizedOfficialFirstName: | HARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2172838540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 0004200 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 210046 | 01 | IL | WPS | OTHER |