Basic Information
| Provider Information | |||||||||
| NPI: | 1518170729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAYLORVILLE MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882624 | ||||||||
| FaxNumber: | 2177577550 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | TAYLORVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625681562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178243331 | ||||||||
| FaxNumber: | 2178241624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOURNE | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2178243331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 282NC0060X | N | Hospitals | General Acute Care Hospital | Critical Access | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 793090 | 01 | IL | MEDICARE PART B WPS | OTHER | 0001115006 | 01 | IL | BLUE CROSS | OTHER | 208522 | 01 | IL | MEDICARE PART B WPS | OTHER |