Basic Information
| Provider Information | |||||||||
| NPI: | 1477276301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DECATUR MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROFESSIONAL FEES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N EDWARDS ST | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178762857 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178768121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2022 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARLAN | ||||||||
| AuthorizedOfficialFirstName: | JUDI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | NETWORK DEVELOPMENT AND PARTNERSHIP | ||||||||
| AuthorizedOfficialTelephone: | 2175882882 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1164477725 | 01 | IL | DMG NPI | OTHER |