Healthcare Provider Details

I. General information

NPI: 1700063179
Provider Name (Legal Business Name): RICHLAND MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E LOCUST ST
OLNEY IL
62450-2553
US

IV. Provider business mailing address

PO BOX 97
OLNEY IL
62450-0097
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-7340
  • Fax:
Mailing address:
  • Phone: 618-395-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036050750
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036060342
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036119328
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209004125
License Number StateIL

VIII. Authorized Official

Name: HARRY BROCKUS
Title or Position: CEO
Credential:
Phone: 618-395-7340