Healthcare Provider Details

I. General information

NPI: 1780321117
Provider Name (Legal Business Name): GRAHAM HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E JACKSON ST
MACOMB IL
61455-2530
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax:
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-647-8613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULIE REEDER
Title or Position: VICE PRESIDENT OF FINANCE & CFO
Credential:
Phone: 309-647-5240