Provider Demographics
NPI:1366486771
Name:PASSAVANT MEMORIAL AREA HOSPITAL
Entity Type:Organization
Organization Name:PASSAVANT MEMORIAL AREA HOSPITAL
Other - Org Name:PASSAVANT SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-479-5527
Mailing Address - Street 1:PO BOX 1977
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62705-1977
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:217-757-6021
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:217-479-5821
Practice Address - Fax:217-243-7406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCB3741OtherRR MEDICARE GROUP#
IL752951OtherHEALTHLINK
IL06932023OtherBLUE CROSS BLUE SHIELD
IL=========OtherIRS TAX ID
IL213771Medicare ID - Type UnspecifiedMEDICARE GROUP#-LOC 99