Provider Demographics
NPI:1407135130
Name:HANNIBAL REGIONAL HEALTHCARE SYSTEM, INC.
Entity Type:Organization
Organization Name:HANNIBAL REGIONAL HEALTHCARE SYSTEM, INC.
Other - Org Name:HANNIBAL REGIONAL MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DIX
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-248-1300
Mailing Address - Street 1:6500 HOSPITAL DR
Mailing Address - Street 2:P O BOX 1239
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6890
Mailing Address - Country:US
Mailing Address - Phone:573-406-5888
Mailing Address - Fax:573-406-5889
Practice Address - Street 1:101 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1436
Practice Address - Country:US
Practice Address - Phone:217-285-5012
Practice Address - Fax:217-285-4519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009247152W00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty