Healthcare Provider Details

I. General information

NPI: 1891766317
Provider Name (Legal Business Name): RED BUD ILLINOIS HOSPITAL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SPRING ST
RED BUD IL
62278-1105
US

IV. Provider business mailing address

PO BOX 503891
SAINT LOUIS MO
63150-3891
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-3831
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number0005199
License Number StateIL

VIII. Authorized Official

Name: RANDY MICHAEL COOPER
Title or Position: SVP FINANCE OP/AUTHORIZED OFFICIAL
Credential:
Phone: 615-221-3840