Provider Demographics
NPI:1205031721
Name:KATHERINE SHAW BETHEA HOSPITAL
Entity Type:Organization
Organization Name:KATHERINE SHAW BETHEA HOSPITAL
Other - Org Name:KSB HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHREINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-285-5834
Mailing Address - Street 1:101 W 2ND ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3076
Mailing Address - Country:US
Mailing Address - Phone:815-284-5710
Mailing Address - Fax:815-285-5893
Practice Address - Street 1:101 W 2ND ST
Practice Address - Street 2:SUITE 203
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3076
Practice Address - Country:US
Practice Address - Phone:815-284-5710
Practice Address - Fax:815-285-5893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2001576251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL=========004Medicaid