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NPI Code Detail

MEDICARE: BEVERLY ENTERPRISES - ILLINOIS, INC.

MEDICARE: BEVERLY ENTERPRISES - ILLINOIS, INC.
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
1314000000XSkilled Nursing Facility

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1105320OTHERILBCBS
247523OTHERILGROUP HP

General Provider Information

NPI Number : 1275628448
Entity Type Code : Organization
Provider Name (Legal Business Name) : BEVERLY ENTERPRISES - ILLINOIS, INC.
Provider Business Mailing Address
First Line : 393 E EDWARDSVILLE RD
Second Line :
City : WOOD RIVER
State : IL
Zip : 62095-1646
Country : US
Telephone Number : 618-259-4111
Fax Number :
Provider Business Practice Location Address
First Line : 393 E EDWARDSVILLE RD
Second Line :
City : WOOD RIVER
State : IL
Zip : 62095-1646
Country : US
Telephone Number : 618-259-4111
Fax Number :
Authorized Official
Title or Position : VICE PRESIDENT
Name : DAVID MERRELL
Credential :
Telephone Number : 479-201-4840
Provider Enumeration Date : 10/04/2006
Last Update Date : 08/22/2020

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