Provider Demographics
NPI:1093083511
Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Other - Org Name:WESTERN ILLINOIS SPORTS MEDICINE & ORTHOPEDIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-833-4101
Mailing Address - Street 1:503 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3313
Practice Address - Country:US
Practice Address - Phone:309-833-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001438207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty