=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821186479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRFIELD MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 NW 11TH ST
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-847-8260
-----------------------------------------------------
Fax | 618-847-8387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 NW 11TH ST
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-847-8260
-----------------------------------------------------
Fax | 618-847-8387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. MICHAEL J BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-847-8260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 0040238
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------