Basic Information
| Provider Information | |||||||||
| NPI: | 1902007610 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HSHS HOLY FAMILY HOSPITAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREENVILLE REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HEALTH CARE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186641230 | ||||||||
| FaxNumber: | 6186649750 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEALTH CARE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186641230 | ||||||||
| FaxNumber: | 6186649750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENNEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 6186903530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0005355 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.