Provider Demographics
NPI:1497861330
Name:PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION
Other - Org Name:PASSAVANT AREA CHILDRENS HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-245-9541
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-245-9541
Mailing Address - Fax:217-479-8781
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:217-245-9541
Practice Address - Fax:217-479-8781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-22
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid