Provider Demographics
NPI:1184668519
Name:PASSAVANT MEMORIAL AREA HOSPITAL
Entity Type:Organization
Organization Name:PASSAVANT MEMORIAL AREA HOSPITAL
Other - Org Name:PRAIRIELAND EMERGENCY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-245-9541
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-245-9541
Mailing Address - Fax:217-479-8781
Practice Address - Street 1:1600 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1136
Practice Address - Country:US
Practice Address - Phone:217-245-9541
Practice Address - Fax:217-479-8781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIELAND EMERGENCY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCD9582OtherMEDICARE RAILROAD ERPHY G
IL342729OtherHEALTHLINK ERPHY GROUP NU
IL6921280OtherBLUE SHIELD
ILCD9582OtherMEDICARE RAILROAD ERPHY G
IL6921280OtherBLUE SHIELD