Healthcare Provider Details

I. General information

NPI: 1649210444
Provider Name (Legal Business Name): PASSAVANT MEMORIAL AREA HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 N WESTGATE AVE
JACKSONVILLE IL
62650-1156
US

IV. Provider business mailing address

PO BOX 1977
SPRINGFIELD IL
62705-1977
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-7275
  • Fax: 217-245-7427
Mailing address:
  • Phone: 217-544-6464
  • Fax: 217-757-6021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: LARRY RAGEL
Title or Position: CFO/VICE PRESIDENT OF FINANCE
Credential:
Phone: 217-479-5527