Healthcare Provider Details

I. General information

NPI: 1063448827
Provider Name (Legal Business Name): MEMORIAL HOSPITAL OF CARBONDALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E. VIENNA SUITE 1
ANNA IL
62906
US

IV. Provider business mailing address

735 CASPER CHURCH ROAD
COBDEN IL
62920
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-1506
  • Fax:
Mailing address:
  • Phone: 618-833-8227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateIL

VIII. Authorized Official

Name: KATHRYN A WHITESIDE
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 618-833-1506