MEDICARE: KATHERINE SHAW BETHEA HOSPITAL

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	251G00000X	Community Based Hospice Care Agency	2001576	IL

General Provider Information

NPI Number	:	1205031721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATHERINE SHAW BETHEA HOSPITAL

Provider Business Mailing Address
First Line	:	101 W 2ND ST
Second Line	:	SUITE 203
City	:	DIXON
State	:	IL
Zip	:	61021-3076
Country	:	US
Telephone Number	:	815-284-5710
Fax Number	:	815-285-5893

Provider Business Practice Location Address
First Line	:	101 W 2ND ST
Second Line	:	SUITE 203
City	:	DIXON
State	:	IL
Zip	:	61021-3076
Country	:	US
Telephone Number	:	815-284-5710
Fax Number	:	815-285-5893

Authorized Official
Title or Position	:	COO
Name	:	MR. DAVID SCHREINER
Credential	:
Telephone Number	:	815-285-5834

Provider Enumeration Date	:	06/15/2007
Last Update Date	:	08/18/2011

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