Basic Information
Provider Information | |||||||||
NPI: | 1629295324 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOOPESTON COMMUNITY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ROSSVILLE MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 701 E ORANGE ST | ||||||||
Address2: |   | ||||||||
City: | HOOPESTON | ||||||||
State: | IL | ||||||||
PostalCode: | 609421801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2173836792 | ||||||||
FaxNumber: | 2173834752 | ||||||||
Practice Location | |||||||||
Address1: | 619 N. CHICAGO STREET | ||||||||
Address2: |   | ||||||||
City: | ROSSVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 609630248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2177484141 | ||||||||
FaxNumber: | 2177486973 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2007 | ||||||||
LastUpdateDate: | 05/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROCKUS | ||||||||
AuthorizedOfficialFirstName: | HARRY | ||||||||
AuthorizedOfficialMiddleName: | F. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2172838540 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   | IL | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QR1300X | 000420 | IL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.