Provider Demographics
NPI:1003068909
Name:FREEPORT REGIONAL HEALTH CARE FOUNDATION
Entity Type:Organization
Organization Name:FREEPORT REGIONAL HEALTH CARE FOUNDATION
Other - Org Name:FHN-FAMILY HEALTHCARE CENTER BURCHARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-599-6000
Mailing Address - Street 1:421 W EXCHANGE ST
Mailing Address - Street 2:PO BOX 268
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4008
Mailing Address - Country:US
Mailing Address - Phone:815-599-7958
Mailing Address - Fax:
Practice Address - Street 1:1010 W FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6600
Practice Address - Country:US
Practice Address - Phone:815-599-7421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1312400020Medicare NSC
433440Medicare PIN