Basic Information
Provider Information | |||||||||
NPI: | 1487664025 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRAHAM HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 210 W WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | IL | ||||||||
PostalCode: | 615202444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096475240 | ||||||||
FaxNumber: | 3096495110 | ||||||||
Practice Location | |||||||||
Address1: | 225 W WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | IL | ||||||||
PostalCode: | 615202443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096474088 | ||||||||
FaxNumber: | 3096495198 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 10/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REEDER | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF FINANCE/CFO | ||||||||
AuthorizedOfficialTelephone: | 3096475240 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1001445 | IL | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 9832 | 01 | IL | BLUE CROSS BLUE SHIELD IL | OTHER |