Healthcare Provider Details

I. General information

NPI: 1558514984
Provider Name (Legal Business Name): KEWANEE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 W SOUTH ST
KEWANEE IL
61443-8354
US

IV. Provider business mailing address

1051 W SOUTH ST
KEWANEE IL
61443-8354
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-7500
  • Fax:
Mailing address:
  • Phone: 309-852-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.000306
License Number StateIL

VIII. Authorized Official

Name: MRS. MARGARET GUSTAFSON
Title or Position: CEO
Credential:
Phone: 309-852-7500