Provider Demographics
NPI:1578504544
Name:HOOPESTON COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HOOPESTON COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:CHARLOTTE ANN RUSSELL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-283-8540
Mailing Address - Street 1:701 E ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:HOOPESTON
Mailing Address - State:IL
Mailing Address - Zip Code:60942-1801
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:801 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1802
Practice Address - Country:US
Practice Address - Phone:214-283-5644
Practice Address - Fax:217-283-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004200261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9222940OtherBCBS
IL210220Medicare ID - Type UnspecifiedPART B CLINIC PAS
IL573370Medicare ID - Type UnspecifiedPART B CLINIC DOCTORS
IL9222940OtherBCBS