Provider Demographics
NPI:1063478782
Name:MASON HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:MASON HOSPITAL DISTRICT
Other - Org Name:HAVANA MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-543-8542
Mailing Address - Street 1:615 N PROMENADE ST
Mailing Address - Street 2:P O BOX 530
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-1015
Mailing Address - Country:US
Mailing Address - Phone:309-543-6600
Mailing Address - Fax:309-543-2089
Practice Address - Street 1:615 N PROMENADE ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644-1243
Practice Address - Country:US
Practice Address - Phone:309-543-6600
Practice Address - Fax:309-543-2089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143457Medicare Oscar/Certification