Healthcare Provider Details

I. General information

NPI: 1568005981
Provider Name (Legal Business Name): GRAHAM HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 23RD AVE
AVON IL
61415-9126
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-647-8613
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-647-8613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULIE REEDER
Title or Position: VP OF FINANCE/ CFO
Credential:
Phone: 309-647-5240