Healthcare Provider Details

I. General information

NPI: 1235225236
Provider Name (Legal Business Name): PANA COMMUNITY HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E 9TH ST SUITE 105
PANA IL
62557
US

IV. Provider business mailing address

101 E 9TH ST SUITE 105
PANA IL
62557-1716
US

V. Phone/Fax

Practice location:
  • Phone: 217-562-2544
  • Fax: 217-562-6288
Mailing address:
  • Phone: 217-562-2544
  • Fax: 217-562-6288

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 Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS LISA MARIE BLOEMER
Title or Position: PRACTICE MANAGER
Credential: CMC &CMIS
Phone: 217-562-6257