Provider Demographics
NPI:1083685986
Name:GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC
Other - Org Name:GATEWAY REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PATIENT FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:PEEK
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3672
Mailing Address - Street 1:PO BOX 503706
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-798-3000
Practice Address - Fax:618-798-3724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005223273R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010779809OtherMO MCAID
10685OtherALLIANCE
10685OtherBC MO
5020040OtherHARRINGTON
103244OtherHEALTHLINK PPO
50040OtherBCBS
IL=========001Medicaid
IL=========001Medicaid