Provider Demographics
NPI:1447221247
Name:GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC
Other - Org Name:GATEWAY REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP FINANCE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3840
Mailing Address - Street 1:PO BOX 503706
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-798-3000
Practice Address - Fax:618-798-3724
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANITE CITY ILLINOIS HOSPITAL COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-30
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005223273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14S125Medicare Oscar/Certification
IL=========0001Medicare ID - Type Unspecified