Provider Demographics
NPI:1386635373
Name:KIRBY MEDICAL CENTER
Entity Type:Organization
Organization Name:KIRBY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TENHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-762-1501
Mailing Address - Street 1:1000 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-2116
Mailing Address - Country:US
Mailing Address - Phone:217-762-2115
Mailing Address - Fax:217-762-1502
Practice Address - Street 1:1000 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-2116
Practice Address - Country:US
Practice Address - Phone:217-762-2115
Practice Address - Fax:217-762-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0001Medicaid
IL=========401Medicaid
IL=========003Medicaid
IL=========003Medicaid