MEDICARE: EAST PHILLIPS COUNTY HOSPITAL DISTRICT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center		CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CC8329	OTHER	CO	RR MCR #
3	FA231008	OTHER	CO	BC/BS PROV #

General Provider Information

NPI Number	:	1073520375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST PHILLIPS COUNTY HOSPITAL DISTRICT

Provider Business Mailing Address
First Line	:	1001 E JOHNSON STREET
Second Line	:
City	:	HOLYOKE
State	:	CO
Zip	:	80734-1854
Country	:	US
Telephone Number	:	970-854-2500
Fax Number	:	970-854-3440

Provider Business Practice Location Address
First Line	:	1001 E JOHNSON STREET
Second Line	:
City	:	HOLYOKE
State	:	CO
Zip	:	80734-1854
Country	:	US
Telephone Number	:	970-854-2500
Fax Number	:	970-854-3440

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL HASSELL
Credential	:
Telephone Number	:	970-854-2241

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	01/04/2023

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Practice Location Address:

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1770553794 — DR. KEVIN JAMES CUCCINELLI MD
Practice Location Address:

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1891733879 — EAST PHILLIPS COUNTY HOSPITAL DISTRICT
Practice Location Address:

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1427065549 — DR. DENNIS J. JELDEN MD
Practice Location Address:

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Directions to “EAST PHILLIPS COUNTY HOSPITAL DISTRICT ” Practice Location

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