Provider Demographics
NPI:1235383951
Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Other - Org Name:MCDONOUGH DISTRICT HOSPITAL SURGICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-833-4101
Mailing Address - Street 1:505 E GRANT ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3352
Mailing Address - Country:US
Mailing Address - Phone:309-833-2868
Mailing Address - Fax:
Practice Address - Street 1:515 E GRANT ST
Practice Address - Street 2:SUITE 211
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3368
Practice Address - Country:US
Practice Address - Phone:309-833-3706
Practice Address - Fax:309-836-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060998208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1647Medicare Oscar/Certification
ILIL1647003Medicare Oscar/Certification
ILIL1647002Medicare Oscar/Certification
ILIL1647001Medicare Oscar/Certification