Healthcare Provider Details

I. General information

NPI: 1366486771
Provider Name (Legal Business Name): PASSAVANT MEMORIAL AREA HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

IV. Provider business mailing address

PO BOX 1977
SPRINGFIELD IL
62705-1977
US

V. Phone/Fax

Practice location:
  • Phone: 217-479-5821
  • Fax: 217-243-7406
Mailing address:
  • Phone: 217-544-6464
  • Fax: 217-757-6021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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