Healthcare Provider Details

I. General information

NPI: 1760994040
Provider Name (Legal Business Name): PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 04/09/2018
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

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-9541
  • Fax: 217-479-8781
Mailing address:
  • Phone: 217-245-9541
  • Fax: 217-479-8781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT L SILTMAN
Title or Position: DIRECTOR, PATIENT FINCNAIAL SERVICE
Credential:
Phone: 217-479-5652