=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295494391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTON MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2021
-----------------------------------------------------
Last Update Date | 12/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEMORIAL DR
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-6722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-657-9001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MEMORIAL DR RM G247
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-6722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-657-9001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF ALTON MEMORIAL HOSPITA
-----------------------------------------------------
Name | DAVID BRAASCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-463-7301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------