Provider Demographics
NPI:1275616740
Name:HOPEDALE MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:HOPEDALE MEDICAL FOUNDATION
Other - Org Name:HOPEDALE MEDICAL COMPLEX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-449-4394
Mailing Address - Street 1:107 TREMONT
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:IL
Mailing Address - Zip Code:61747-0267
Mailing Address - Country:US
Mailing Address - Phone:309-449-3321
Mailing Address - Fax:
Practice Address - Street 1:107 TREMONT ST.
Practice Address - Street 2:
Practice Address - City:HOPEDALE
Practice Address - State:IL
Practice Address - Zip Code:61747-0267
Practice Address - Country:US
Practice Address - Phone:309-449-3321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========925006Medicaid
IL=========925006Medicaid