Healthcare Provider Details

I. General information

NPI: 1083685986
Provider Name (Legal Business Name): GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MADISON AVE
GRANITE CITY IL
62040-4701
US

IV. Provider business mailing address

PO BOX 503706
ST. LOUIS MO
63150-3706
US

V. Phone/Fax

Practice location:
  • Phone: 618-798-3000
  • Fax: 618-798-3724
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number0005223
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0005223
License Number StateIL

VIII. Authorized Official

Name: TARA PEEK RICHARDSON
Title or Position: VP OF PATIENT FINANCIAL SERVICES
Credential:
Phone: 615-221-3672