Provider Demographics
NPI:1295834208
Name:WABASH GENERAL HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:WABASH GENERAL HOSPITAL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASPER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PURVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-262-8621
Mailing Address - Street 1:1418 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-2638
Mailing Address - Country:US
Mailing Address - Phone:618-262-8621
Mailing Address - Fax:
Practice Address - Street 1:1418 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2638
Practice Address - Country:US
Practice Address - Phone:618-262-8621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WABASH GENERAL HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002865282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009300000OtherBLUE SHIELD
IL376013525401Medicaid
I32037Medicare UPIN
IL376013525401Medicaid
IL797870Medicare ID - Type UnspecifiedJULKO FULLOP
E02611Medicare UPIN